Treatment of the Morphine Habit. 





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ON THE 



TREATMENT OF THE MORPHINE HABIT. 



DR. ALBRECHT ERLENMEYER. 



TRANSLATED FROM THE GERMAN. 



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N~^ .V w^\, 





I860: 
GEORGE S. DAVIS, 

DETROIT, MIOH. 



* 



■ 



1 0- 



Copyrighted by 
GEORGE S. DAVIS. 



PREFACE. 



The great work of Dr. Albrecht Erlenmeyer on the Mor- 
phine Habit was published in 1883; the second edition ap- 
peared in 1887. 

It is much to be desired that the entire book might ap- 
pear in an English translation; such a volume would, how- 
ever, be too large for the Leisure Library series. 

One chapter only of this work is here reproduced, viz., 
that pertaining to Treatment. Nor is this chapter given in 
its entirety, as it seemed best to the translator to make some 
abridgments, and it is especially under the head of the cocaine 
habit that such abridgment appeared to be demanded — that 
topic being treated in the original with a diffusiveness, and a 
minuteness of detail, which, although adding to the scientific 
value of the entire work, would have been out of proportion in 
this translation. The aim of this little volume, in fact, is to 
give a plain, concise and practical presentation of the therapy 
of morphinism according to Erlenmeyer's teachings. The 
translator has made other brief abridgments according to his 
best judgment, the omitted passages being mainly repetitions, 
or paragraphs that would have been unintelligible without the 
reproduction of parts of the book in other chapters to which 
the omitted portions refer. 

To Mr. Carl Meinerth, an accomplished German scholar 
the translator is mainly indebted for assistance in the transla- 
tion of the text. Dr. Ernest H. Noyes has added a chapter of 
reports of cases occurring in Erlenmeyer's clinic, and illustra- 
tive of his methods of treatment. 

E. P. Hurd, M. D., 
Nkwburyport, Mass., April 10th, 1889. 



THE TREATMENT 



THE MORPHINE HABIT. 



SUMMARY. 



GENERAL PRINCIPLES OF TREATMENT. 

I. Methods of Withdrawal, — Gradual Method. — Sudden 
Method. — Rapid Method (a modification of the second). 

II. Where shall the Treatment be earried out, and what are 
the Means necessary for Success? — At Home. — Insane 
Asylums. — Public Institutes for the Morphine Cure. — 
Private Institutes. — Regulations for Institutes ; for 
Home Treatment. 

III. Treatment of the Symptoms Developed by Abstinence. — Col- 

lapse. — Delirium. — Toxaemia. — Vomiting. — Diarr- 
hoea and Abdominal Pains. — Pains in the Calf ol the 
Leg. — General Restlessness. — Insomnia. — Rest in Bed. 
— Nutritious Food. — Baths. — Fresh Air and Exercise. — 
Treatment of Mental Disturbances. — Hysterical Symp- 
toms. — Causal Indications. — Simulations of Sufferings. 

IV. The Cocaine Treatment. — Its Abuse. — The Cocaine Habit. 

— Physiological and Toxicological Effects of Cocaine in 
the Treatment of Morphiomania. 

V. Prevention of Relapses. — The Habit is Not a Primary but 
a Secondary Malady. — Treatment of the Original Disease 
After Withdrawal of Morphia; Before Withdrawal. — 
Secondary Symptoms arising from Abstinence. 



VIII. 

VI. General Prophylaxis. — Assistance by the Government. — 

Assistance which Might be Rendered by Druggists; by 
Physicians. — Public Warnings. — Attitude of the Press 
towards the Habit. 

VII. Reports of Cases. 



INTRODUCTION.* 

The words morphinomania, or morphiomania, and morphin- 
ism are used to designate the sum of morbid phenomena 
resulting from the abuse of morphia. The word morphinism 
may be compared to alcoholism, and morphiomania to dipso- 
mania: the propriety of calling inveterate addiction to the 
morphine habit a mania is obvious to any one who considers 
how completely the will and moral sentiment of the victim 
are dominated by the passion of the narcotic. 

This is a disease of modern life, and of recent origin. 
Opium eating, the sum of whose baneful effects has been 
called thebaism, has been practiced for centuries in the East, 
and in China numbers among its victims one-fifth of the entire 
population. But opium eating and opium smoking have never 
prevailed to any great extent among Western nations, while 
within a few years — since the time, in fact, when the hypoder- 
mic syringe first came into use, about the year 1859 ( we hardly 
need go back to the discovery of morphine by Sertiirner in 
1817) — a new vice has sprung into existence more peculiarly 
suited to the temperament and habits of Occidentals, which on 
the Continent of Europe, and in this country has made thous- 
ands of victims, and is said to be steadily on the increase. 
Synchronously with the discovery of the wonderful pain- 
assuaging properties of hypodermic injections, morphinism 
became known. 

The way in which this malady is developed generally is as 
follows: A patient shall be suffering from frequent attacks of 
angina pectoris, sciatica, hepatic colic, or some other very 
painful affection, for which his physician has resorted to subcu- 
taneous injections of morphine. The relief has been speedy 
and magical. The painful disease persisting, the hypodermic 



*By the translator. 



X. 

injections are continued, but larger and still larger doses are soon 
required to produce the effect which small doses at first pro- 
duced. The patient obtains a hypodermic syringe of his physi- 
cian or of some druggist, and a quantity of morphine, the 
doses of which he readily learns (sometimes a prescription 
given him by his physician enables him to get a standard 
solution any number of times he desires), and he is now on 
the downward road; he has become a morphiomaniac. This 
is the way the vice comes to be generated; no one ever be- 
comes a morphinist without some powerful motive; pain, 
mental distress, or insomnia. If physicians, say Levinstein, 
Zambaco, and Erlenmeyer, would take more pains to search out 
and remove the original cause of the morphine malady; if they 
would be more sparing in the use of hypodermic injections, never 
resorting to them till other and safer means have failed; if, 
moreover, they would see to it that these hypodermic injections 
shall never be administered by the patient to himself, but 
always by the medical attendant; and if, finally, the apothe- 
caries could be brought to exercise proper care and vigilance 
in dispensing morphine, never giving it except under a physi- 
cian's orders, the evil would be virtually suppressed. 

While alcoholic abuses are especially prevalent in the 
lower walks of life, the morphine vice is almost peculiar to the 
higher, as it is in these classes especially that we meet with 
the nervous temperament and painful neurotic maladies (as 
migraine), excessive cerebral stimulation, and all the developed 
passions and morbid cravings connected therewith. 

The onset of morphinism is generally gradual; a person 
may long use daily injections of one-twelfth to one-sixth of a 
grain with apparently no bad results, unless it be an increase 
of the reflex excitability, which after a few weeks gives place 
to depressant symptoms. If the daily doses of morphine, 
necessitated by the supervention of these symptoms, be grad- 
ually increased after a few months (according to Levinstein, 



XI. 

six or seven), the system becomes saturated with the poison; 
there is marked general disturbance of nutrition, the appetite 
fails, and emaciation appears. We can hardly, with Von Boeck,* 
attribute this train of mobid phenomena to diminished absorp- 
tion of food in consequence of the catarrh of the stomach and 
intestine which now exists, although this is undoubtedly one 
factor in the failure of nutrition. Morphine diminishes in the 
economy the oxidation processes on which the movements of 
assimilation and disassimilation depend; it is a true proto- 
plasmic poison. By its action on the higher nervous centres 
it undoes the finished results of evolution by a sort of reverse 
process to that which goes on in normal development: its 
effects are, in fact (to quote from Lauder Brunton), exactly 
similar to those produced by the successive removal of the 
different parts of the nervous system from above downwards; 
the functional activities of the cortical ganglia being progres- 
sively suspended, the individual becomes more and more like 
the brute or the automaton. 

This action, it may be stated, is not peculiar to morphine, 
but is possessed by the narcotics generally, by chloral, and by 
alcohol. 

The excitability of the sensory nerves is everywhere 
diminished in confirmed morphinism, hence the absence of 
the sensation of hunger, the imperfect reaction of the usual 
stimuli, etc. Torpor of the nerves manifests itself in a variety 
of ways, from a capillary stasis (vaso-motor paralysis), with its 
consequent depression of function, to the muscular enfeeble- 
ment and the mental dilapidation which characterize chronic 
cases of morphine poisoning. 

Probably there are few conditions of misery more poig- 
nant. The morphinist suffers from insomnia, nightmare, hal- 



♦Ziemssen's Cyclop., vol. xvii, Art. "Opium and Morphine Poi- 
soning." 



XII. 

lucinations, trembling of the hands and tongue, impotence, 
hypochondriac moroseness, neuralgias, and frequent febrile 
attacks; he is lean and cadaverous, his face is expressionless, 
his eyes have lost their brilliancy, his memory is poor, the 
power of mental application is absent; he becomes treacherous, 
suspicious, untruthful in fact almost demoralized; a full in- 
jection of morphine for a time relieves him, and brings back a 
sense of bien etre and the ability to work, but the relief is of 
but fleeting duration, and the miserable victim soon again 
sinks into the abyss of despair. 

As to the amoaat of morphine which persons confirmed 
in the habit require, this is sometimes very large: seven or 
eight grains a day would be regarded by many a morphinist as 
a very moderate allowance. Physicians in New England are 
acquainted with morphine habitues who have been known to 
take doses of from fifteen grains to a scruple. This quantity, 
when injected into the cellular tissue under the skin, has been 
known to cause troublesome abscesses, such as often, in fact, 
attend morphine injections in the cachectic. 

The morphine habit is difficult of eradication. The per- 
centage of reformed drunkards is greater than that of reformed 
morphiomaniacs. The baneful drug has become a necessity; 
if withheld, every cell of the organism cries out in agony. The 
harmonious exercise of function in the economy cannot be 
maintained without morphia; the organs have, in fact, ad- 
justed themselves to a new and artificial condition in which 
the great element of equilibration is that deadly alkaloid. 
Hence the removal of morphine gives rise to an all-powerful 
organic craving. Yet the pernicious habit must be broken, 
the morphine must be discontinued, if the poor victim of the 
vice would ever rise to the dignity of true manhood again. 

Hard as the struggle to break off may be, many have suc- 
cessfully gone through the trying ordeal. It is essential to the 
success of the treatment that the morphinist shall desire to be 



XIII. 

cured, and shall co-operate with his physician and friends in 
the earnest endeavor for restoration. 

There are two methods of leaving off: the sudden method, 
and the gradual method. Levinstein is the conspicuous advo- 
cate of the sudden method, which theoretically is the best. 
The supply of morphia is at once stopped and forever. It is 
to be remarked that this method of weaning from alcoholism is 
generally the best. But, in respect to morphinism, the practi- 
cal difficulties in the way of sudden suppression are very great; 
dangerous collapse is liable to ensue, and wild and maniacal 
delirium, and the treatment can only be carried out in an in- 
stitute where the patient can be properly watched and guarded. 
With robust patients, however, it is probably the better method. 
In about a week the worst symptoms are over, and the patient 
is on the road to convalescence. 

The gradual method advocated by Burkhart, or the modi- 
fication first produced by Erlenmeyer and called by him " the 
quick method," or "the modified slow method," is the one in 
use by most specialists. 

The patient is gradually weaned from morphine; the injec- 
tions are not given so often, or more water and less morphine 
are given with each injection. By this method, the acute 
accidents are avoided, but the patient is long kept in a state of 
irritation, teased, and tantalized without being satisfied. The 
nightly doses are throughout the weaning process the largest. 
Collapse is to be met by full doses; this condition may often 
be prevented by the administration of alcoholic stimulants, 
coca, food. Restlessness and insomnia may be combatted by 
chloral, urethan, bromides, with, if occasion demand, a little 
morphine. The attempt during the weaning process to sub- 
stitute cocaine for morphine has not been very successful. It 
is fitly characterized by Erlenmeyer as the casting out of 
Satan by Beelzebub. 



XIV. 

Instances are very few where the confirmed victim of the 
morphine habit by will power alone has succeeded in eman- 
cipating himself from his bondage. The drunkard has now 
and then forsaken his cups, and the tobacco victim his pipe or 
cigar, never again resuming the baneful habit; and all by the 
strength of a will which, once asserting itself, is never again 
overcome, despite temptations and the intense craving for an 
accustomed stimulus. But the unhappy morphinist, when 
once brought to view with horror the abyss of ruin in which he 
is sinking, is not likely to escape without extraneous aid. 
This is due to three reasons: First, the strength of the pas- 
sion for the narcotic, which for a time becomes increasingly 
imperious every day; second, the demoralized condition of the 
individual, whose finer sensibilities and whose better nature 
have been impaired by the long continued action of the poison 
on the cells of the cerebral cortex; third, the feeble tension of 
the will power, or, more properly speaking, of those higher 
energies which represent action inspired by superior motives. 
Hence, the morphiomaniac can seldom hold out long in the 
struggle against temptation, and he is in need of the help 
which the co-operation of friends and medical assistants can 
give him. There will be a time, even, when restraint will be 
necessary, as during the first fortnight of the withdrawal; and 
hence it is not only desirable, but practically essential, that the 
morphine habitue who would be cured should surrender for a 
time his liberty to the guardianship and care of persons 
thoroughly competent to treat his disease; and it is only within 
the walls of a properly equipped institute that the withdrawal 
treatment can be properly carried out. 

One disadvantage of the gradual method (alluded to by 
Erlenmeyer) is the long time during which the patient must 
remain in the institute. The principle of the treatment being 
"progressively to diminish the daily quantity of morphine in- 
jected, to act slowly, and sometimes to decrease only by 



XV. 

several milligrammes a day," months are often required to 
thoroughly wean the patient from morphine. The treatment 
by the gradual method is therefore both expensive and painful; 
the sum of the patient's sufferings is spread over weeks, or 
even months, instead of being concentrated into a few days, 
after which the distress is principally over, as in Erlenmeyer's 
rapid method. 

It is needless to say that the gradual or " tapering off " 
method cannot be effectively carried out at home, or in a pri- 
vate boarding house. No patient was ever yet weaned from 
morphine in that way; at least, no inveterate case was ever so 
cured. 

One great obstacle is the facility with which the patient 
can cheat the physician and obtain clandestinely his supply of 
morphine ; and this difficulty, as Erlenmeyer says, even 
attends the attempt to carry out the gradual method of with- 
drawal in a private institute. 

As an illustration of Erlenmeyer's manner of withdrawal 
— his so-called rapid method — we will take a case which he has 
reported, viz., that of a physician aged 29 years, who had been 
made a morphinist by repeated attacks of supra- orbital neural- 
gia. This gentleman had been using one gramme (fifteen 
grains) of morphine daily, subcutaneously. 

On the first day of the treatment, the supply of morphine 
was reduced to 0,33 (five grains) On the second day, the 
supply was still further cut down to 0.12 (two grains). On the 
third day, it was reduced to 0.09 (one and one-half grains). On 
the fourth day, the morphine was reduced to 0.06 (one grain). 
This was all the morphine that was given hypodermically. A 
full dose of laudanum (25 drops) was administered on the sixth 
day, on account of diarrhoea. Alcoholic stimulants, bromides, 
chloral, concentrated broths, milk, etc., were given according 
to'indication. In ten days' time the patient was weaned. 

A patient that had been using daily quantities of 0.5 to 



XVI. 

0.6 (seven and one-half to nine grains), is, on the first day of 
the treatment, cut down to 0.2 (three grains). The second 
day, the morphine is reduced to 0.1 (one and one-half grains). 
On the third day, the same amount is given. On the fourth 
day, 0.05 (three-fourths of a grain) suffices. On the fifth day, 
there is necessity for 0.06 (one grain). On the sixth day, 0.03 
(one-half grain) is administered. On the seventh day, 0.01 
(one-sixth grain). After this, the morphine is discontinued 
altogether. The supervention of diarrhoea requires an occa- 
sional dose of laudanum. 

Such, in brief, is Erlenmeyer's method of treatment 
which is the result of fifteen years' experience and study, and 
which, under the supervision of this German authority and in 
his institute, has been eminently successful. 



THE TREATMENT OF THE MORPHINE 
HABIT. 

GENERAL PRINCIPLES OF TREATMENT. 

The treatment of the morphine habit is threefold: 
First, the use of the poison must be discontinued; 
second, the physical and mental disturbances arising 
during the period of withdrawal must be combated; 
and third, after the patient is cured, means must be 
taken to prevent a return to the habit. 

Before taking up these points seriatim, a few 
words about the general principles of treatment seem 
necessary. 

During the entire period of abstinence, the 
craving for morphine enters as a very important 
element, and in consequence of this craving, the 
patient is frequently utterly uncontrollable. Then, 
when the habit is partially overcome, the danger of a re- 
lapse is always to be borne in mind and provided against. 
The morphine habitue is not only devoid of candor 
and truth, but his sense of right and wrong is con- 
siderably blunted. This psycho-pathological con- 
dition in connection with the bodily sufferings of the 
abstinence period, demands great sagacity and long 
continued watchfulness on the part of the medical 
attendant. At that time, patients try the most cunning 
and fraudulent means to obtain their morphine; 



fortunately, however, the longer they are thwarted in 
their efforts by reliable watchers and strict control, 
the more sure they are gradually to lose the desire 
and habit until these finally disappear. Should the 
control over the patient be lost, or he be dismissed from 
the hospital before a perfect cure has been effected, 
a relapse into the habit will be sure to follow. It is 
therefore necessary, in order to obtain a favorable 
result, to devote less time to fulfilling the first indica- 
tions— witholding the drug, and combating the first 
and immediate effects of this withdrawal — than to the 
longer period of convalescence, when the patient is in 
danger of again yielding to the old habit; the treat- 
ment must therefore, above all, be directed to over- 
coming the habit. The treatment resorted to must 
moreover, be one of absolute safety to the patient, 
and must have the guarantee that he cannot possibly 
supply himself with opiates or substitutes. 

The time required to effect a cure is an important 
consideration, for the business or profession of the pa- 
tient will rarely allow more than six weeks to be devoted 
to the treatment. How these weeks are to be spent 
to the best advantage, it is the object of this treatise 
to set forth. 



CHAPTER I. 

METHODS OF WITHDRAWAL 

There are three methods of withdrawal: 
i. The gradual mode. 

2. The sudden mode. 

3. The rapid mode. 

I. THE GRADUAL MODE. 

This is the oldest of the various methods of dis- 
continuance; the first in vogue, and till recently, prac- 
tised by almost all physicians in the treatment of morph- 
iomania. I myself formerly depended on this method, 
but being convinced of its unsatisfactory character, 
some years ago I abandoned it for what has proved to 
be a more rational system. The nature of this mode 
of treatment is indicated by its name. It is the 
"tapering off" method of the English. The daily 
dose of morphine is decreased, by a very small frac- 
tion, then the drug is finally left off altogether. The 
amount of decrease each day is made dependent on the 
appearance or absence of certain symptoms known as 
phenomena of abstinence. The more pronounced these 
symptoms and the greater their severity, the smaller 
must be the reduction of the opiate. The patient has no 
special nursing, and is not watched, but is left to pursue 
his ordinary mode of life. It is not necessary that he 
be taken to a hospital or asylum or other institution 



especially equipped for the benefit of this class of pa- 
tients, but he is treated at home or at his boarding house, 
as the case may be, the physician having care to pre- 
vent the baneful drug from being in some way sup- 
plied. The uncomfortable effects of the withdrawal 
of the opiate are not so conspicuous as in the case of 
sudden withholding; this very diminution in the in- 
tensity of the symptoms is, however, often the result 
of clandestine obtention of the drug and its secret use 
by the patient. I will now state tha disadvantages of 
this method. 

I must, first of all, observe that it is a matter of 
exceeding difficulty so to control the patient as to 
prevent his obtaining morphine in some secret way. 
Since it is the first aim of our treatment absolutely to 
stop the use of the drug, it is evident that a plan 
of cure which cannot guarantee such withholding, 
must be inefficient, and such is the case with the 
gradual method. I do not hesitate to confess that the 
greater number of the patients whom I have treated 
by this method have deceived me, and this is the more 
remarkable from the fact that the arrangements of our 
private institute make control of our patients com- 
paratively easy. It is curious to recount how these 
patients sometimes procured their morphine. One ob- 
tained his in his private letters; another got a morph- 
ine solution in packages; a third (a female) had a 
dress sent to her, in the lining of which morphine in 
powder had been sewed. Others procured the drug 



— 5 — 
from the apothecaries of the neighboring towns. 
Another stole, from my office, my hypodermic case, 
and still another stole opium from his next door 
neighbor; and many of my confreres have had a sim- 
ilar experience. 

A second equally great disadvantage of this 
method is the prolongation of the morbid phenomena 
which characterize the abstinence period; the patient 
is kept in misery, and loses strength and flesh. 

I cannot agree with those who affirm that the 
patient can better endure the abstinence symptoms 
under the slow than under the sudden method. The 
symptoms might be less severe for a single day, but 
surely the sum of discomfort will be greater during 
the slow process of leaving off, than during the 
quicker processes. A gradual treatment drags along 
three or four or even more weeks; the patient cannot 
recuperate, and convalescence is very tedious. The 
affirmation which has been made against the quick and 
in favor of the gradual process — that the organism 
can better endure lesser and more prolonged pertur- 
bations and strains than stronger and more rapid — 
contradicts experience in all departments of pathology. 
I must call your attention to the fact that the patient 
during the carrying out of the gradual method of treat- 
ment is not spared a single symptom peculiar to the 
sudden method excepting perhaps the collapse. 
what he gains in the lesser intensity o\ the symptoms, 
he loses in the longer duration. 



Another disadvantage of considerable importance 
consists in the consumption of the whole time avail- 
able for the therapy; there remains no time for that 
recuperation without which a lasting success is unat- 
tainable. In most cases the patient is allowed to leave 
the institute or other place of treatment when he is 
only two, three, or at the most eight days freed from the 
habit. He goes away with a brandy bottle in his 
pocket, and some kind friend or attendant is some- 
times found who is considerate enough to give him 
a little opium besides. With such a termination of 
the treatment, the dismissed patient will probably 
on his way home stop at the store of the nearest 
apothecary and get a hypodermic syringe and some 
morphine. But on the records of the institute appear 
the gratifying words: " Discharged cured." 

That such a method of treatment has no claim to 
earnest and scientific consideration, must be apparent 
to any one whose professional judgement cannot be 
befogged by the interests of competition, and who has 
at the same time the courage to confess mistakes 
formerly committed. 

No benefits are derived by the patient from this 
method; the only benefits are realized by the physician 
and his institute. 

Therefore I do not hesitate to declare that this 
slow method is wholly unreliable and unsatisfactory. 
I have had ten years of experience with it in our insti- 
tute, only to be more and more convinced of its 
worthlessness. 



Despite the most strenuous efforts of the physi- 
cian in the interest of his patient, he has no guaranty 
that he will achieve success. It is only in the case of 
very weak patients whose bodily condition is much 
reduced, that this " tapering off " process is to be rec- 
ommended. 

Burkart gives two modifications for facilitating 
the breaking off of the habit. One of them is to give 
the patient at the close opium instead of morphine. 
Here the symptoms following the discontinuance of 
the morphine (abstinence symptoms) are by the 
opium substitute covered up, or, in other words, staved 
off j nothing is, however, gained, for the opium must 
itself be given up, and abstinence therefrom causes 
just the same sufferings as attended the suppression 
of the morphine. Patients devoted to the abuse of 
narcotics, whether these be opium, morphine, Indian 
hemp, or chloral, are susceptible to like sufferings 
when the use of their favorite drug is abandoned. 
The same may be said of alcohol. 

The other modification of Burkart consists in 
giving the patient large quantities of water to drink 
instead of injections of morphine. He declares that 
this has a favorable effect on the stomach, and lessens 
the desire for morphine. This method of course is 
not applicable where vomiting is a symptom. 



THE SUDDEN METHOD OF WITHDRAWAL 

Levinstein was the first exponent and defender 
of this method, which is now called the Levinstein 
method. 

The principle of this method consists in the pa- 
tient being at once wholly deprived of the use of mor- 
phine. When he enters the institute, his supply is 
stopped, and he is kept under constant surveillance so 
that he can obtain no more. He is generally put to 
bed, and kept there a while. 

The carrying out of this method is on the whole 
very simple. On entering the hospital, the patient is 
given a bath. Meanwhile his clothing is carefully 
searched for morphine or oprcL.i. After again putting 
on his clothes, he is taken into a room away from 
his other clothing or baggage, to which he is denied 
access lest he should surreptitiously obtain morphine. 
It is remarkable how cunningly patients try to smuggle 
morphine into the Institute; this they attempt with 
full knowledge beforehand of the struggles which they 
will be obliged to go through at the Institute. These 
schemes, of course, must be thwarted, or success is 
hopeless. Levinstein has recorded quite a number of 
such cases of fraud, when patients smuggled morphine 
in their cigar boxes, in book-marks, watch-cases, and 
even within the soles of their slippers. No doubt 



— 9 — 
other physicians who are experts in the treatment of 
the morphine habit can recount similar experiences in 
cheating. When the impossibility of obtention of 
morphine is realized at the start, the symptoms 
peculiar to the abstinence soon appear, the time being 
' dependent on the quantity of morphine used for the 
last injection; generally in less that twelve hours. 

The Delirium rnaniacale, one of the first symptoms 
of the sudden withdrawal, which is always connected 
with certain dangers to the attendants, cannot, of 
course, be treated in every place, and by everybody. 
In order that this period of high excitement may pass 
safely, certain precautions and means for security of 
persons and property are necessary. Above all, it is 
important that the part of the hospital where the pa- 
tient is treated, shall be separated from all other 
apartments and wards. Not only must the patient be 
isolated in order to prevent any possible obtention of 
drugs, but the other patients must not be disturbed 
by the maniacal cries and noise of the morphine 
victim. The room in which the latter is undergoing 
treatment must contain no movable furniture, or any 
utensils that can be broken. A strong bedstead, a 
night-chair, and a common chair or lounge is all that 
is required. All kinds of smaller furniture and vessels 
are strictly to be removed out of the way, as they may 
become dangerous weapons in the hands of the ex- 
cited patient; especially must knives, scissors, etc., be 
kept away. The doors are to be securely locked, and 



the windows are to be so arranged that no danger 
whatever can be feared. Heating and lighting ar- 
rangements require great care. It is recommended 
to have an adjacent room free,, for meals or entertain- 
ment of company, where the patient may spend quiet 
hours, and where also, may be kept on hand the 
necessary remedies for certain symptoms as they may 
arise: wine and brandy, and ether, also ice water, 
etc. Cooking appliances should also be conveniently 
at hand, and a bath-room should be readily accessible. 
The assistants and servants must be persons on 
whom for conscientiousness and fidelity you can rely; 
the subordinate medical attendants and the nurses 
must not be susceptible to persuasion or to bribery, so 
that all possibility of obtention of morphine shall be 
out of the question. The physician in chief or his 
subordinates must be with the patient night and day 
during the first few days of the treatment, when the 
struggle is greatest; there will be a collapse of the 
vital forces, and it may be a matter of life or death 
for the patient, and in this hour of danger, ripe experi- 
ence, presence of mind and readiness in emergencies 
are necessary in physicians and attendants. They 
must pitilessly resist the importunities of the patient 
for morphine, while, at the same time, they must not 
lose their compassion and sympathy for the poor suf- 
ferer. There will be numerous symptoms constantly 
occurring, such as vomiting, diarrhoea, restlessness, 
which will demand attention and will keep the medi- 



cal attendant and nurses busy; there will for a time, 
in fact, be no rest for anybody. The responsibility of 
keeping the patient from inflicting injury on himself 
is no light strain on the nerves of the physician, who 
must exercise untiring vigilance, and no one can en- 
dure this strain more than twelve hours without re- 
spite and rest. In fact, the severity of the task renders 
frequent change with fresh attendants necessary, and 
an institution which attempts to carry out this method 
of cure is obliged to keep on hand a large cortege of 
assistants and nurses. Levinstein, as a result of his 
experience, recommends that the female nurses em- 
ployed in such cases should be persons of considerable 
character and mental culture, who may exercise a good 
moral influence over the poor victim, and otherwise 
keep him from excesses which he might commit in the 
presence of less cultivated attendants. For my own 
part, I have found this advice sensible, and I place 
great reliance on my corps of well trained and edu- 
cated female nurses. 

In order to put the value of this method in the 
proper light, I will here state its advantages and dis- 
advantages: 

Amongst the advantages, the certainity of success 
stands foremost. As already remarked, under the 
strict regulations of the institute it is next to impos- 
sible for the patient to obtain morphine; the isolation 
alone prevents this. Another benefit— although not 
acknowledged by all — is the rapidity of the cure. For 



12 

in from four to six days the worst symptoms are over, 
and after that the convalescence of the patient follows 
rapidly. 

The disadvantages of the process are: It is almost 
impossible to practise this method in every hospital, as 
without isolation of the morphinist, the other patients 
would suffer too much by the noise and disturbance; 
besides, it is a very expensive method of treatment. 
Another disadvantage is the danger to life of the pa- 
tient through the sudden withdrawal of his accustomed 
drug. 



3- 

THE RAPID METHOD OF WITHDRAWAL 

A modified method of discontinuance had already 
been employed by Levinstein, though only in severe 
cases of disease or weakness where it would be danger- 
ous to apply the sudden method, as in phthisis, em- 
physema, heart disease, etc., and in the case of very 
sensitive persons, especially women. 

In my endeavors to find and develop a method 
which would be only of benefit and could never be an 
injury or disadvantage to the patient, I began with 
this modified system; I have further improved upon 
it, and now rely upon it almost exclusively. Formerly 
I called it the modified slow method; I now call it the 
rapid mode. 

My method has really nothing in common with 
Levinstein's modified mode of withdrawal. By the 
latter process, the patient without regard to the doses 
which he had previously been taking, is at once, for 
the first two or three days of his treatment, put on the 
short allowance of five centigrammes (about a grain) 
of morphine. This virtually amounts to the sudden 
method of withdrawal of which I have before spoken, 
and takes no account of accustomed doses, the dura- 
tion of the habit, and the condition of the patient; it 
is, in fact, applied to every case whose treatment 
seems to require modification in consideration of the 
circumstances above mentioned. 



— 14 — 

The nature of the method which I now advocate, 
consists in as rapidly as possible removing the mor- 
phine, though not suddenly, the aim being to avoid 
any danger of death. My experience has taught me 
that from six to twelve days are sufficient to accom- 
plish the weaning, although the time required for a 
cure depends largely upon the quantity of morphine 
which the patient has been in the habit of taking, the 
duration of his bondage to the habit, and the number 
and kinds of "cures" which he has already passed 
through, which make each following treatment more 
difficult; lastly, on the age and physical constitution 
of the patient. During the first two to six days, I 
endeavor to withdraw altogether habitual doses of 
from thirty to sixty centigrammes (5 to 8 grains), 
and find that ten days are sufficient, without collapse 
ensuing, or disturbances in the breathing or pulse, for 
the withdrawal of daily doses amounting to 1.50 to 2 
grammes of morphine. 

I vary the manner of morphine withdrawal, ac- 
cording to individual cases. I sometimes cut down 
the habitual dose by one-half, which diminished 
quantity I allow to be repeated once or twice during 
the weaning process. Or the first reduction may be 
more than one half, as my judgement may dictate. 
It is necessary carefully to study your patient's 
peculiarities, as all cases cannot be included under 
one iron rule. Sometimes I make no reduction dur- 
ing the first few days, keeping the case under observa- 



— r 5 — 
tion, and noting the symptoms. But when once I 
seriously begin the treatment, I find that the greater 
the reduction in dose effected at the outset, the greater 
is the subsequent gain. 

This maximum reduction is generally quite easily 
borne by the patient, who in most cases has come into 
the Institute "full," as it is called, having taken a much 
larger dose than usual, preparatory to giving up the habit 
altogether; the effect of this larger dose lasts over the 
first and often through the second day of the sojourn 
at the Institute. Most morphinists are in the habit of 
taking, in order to fit them for their daily tasks, a cer- 
tain quantity of morphine over and above what they 
really need to keep them in trim; this extra quantity I 
call a "surplus dose," and the withdrawal of this sur- 
plus dose at the commencement of the treatment is 
easily borne. 

Again, the patient is removed from his business 
and other cares of life, and the rest and comforts of 
the hospital exert a beneficial influence on both mind 
and body; he requires less morphine than before. He is 
for the most part in good physical condition on enter- 
ing the institute, and usually eats well during the first 
few days. Lastly, there is something in the fact that 
many patients confess to the habit of using more mor- 
phine than they really do use, consequently they do 
not suffer as much as might be expected from the re- 
duction. 

I keep up the evening doses the longest, giving 



— i6 — 

these for several days in the reduced quantity first 
allowed; the object of this is to enable the patient to 
get all the sleep possible. Furthermore, I give the 
patient food after each morphine injection, as he is 
more disposed to eat and be benefited by food during 
the exhilaration {euphoria) which follows the dose; by 
the regular administration of food at these times (and 
when he can bear it), too great diminution of his 
strength is prevented. The most violent symptoms 
generally occur with doses of o.io to 0.075 ( J i & rs - 
to 1 gr.); later on there is improvement in the symp- 
toms, as shown by sleep and the desire for food. 

The general arrangements for the rapid cure are 
the same as those prescribed for the sudden method. 
The matter and manner of isolation from all outside 
communication is the same for both modes. Only 
the sick-room can be of a more genial and cheerful 
character, and the cell-like security necessary for the 
maniacal condition of a patient under the sudden 
withdrawal system is not here required. 

Concerning the symptoms which take place dur- 
ing this mode of treatment, they are essentially the 
same as those which characterize the gradual method, 
with the exception of the collapse. Individual differ- 
ences, such as are witnessed in the carrying out of 
every other kind of treatment, are of course not want- 
ing. 

As a rule, the symptoms following abstinence 
show themselves with greater severity under this 



— 17 — 

method than under the gradual, but they are consid- 
erably weaker than those which attend the sudden 
withdrawal. One great advantage, however, is that 
even the severest symptoms do not last long, and that 
the patients get over the worst in a few days, while 
they suffer for weeks under the slow method of treat- 
ment. 

Morphine habitues who have gone through the 
different "cures" are almost unanimous against the slow 
treatment. One of my patients, himself a physician, 
who has twice tried Burkart's slow and twice Levin- 
stein's sudden method, has assured me that my rapid 
method is far the easiest; and he affirms that he would 
rather, if necessary, submit to the sudden than to the 
slow mode of cure, the latter being a terrible ordeal 
to the sick man, who, to quote my patient's language, 
"suffers like the dog whose tail is cut off by inches." 
Another, also a medical man, who voluntarily left 
Burkart's slow "cure" after one week and came to 
my institute, where in five days he was thoroughly 
weaned, expressed his opinion in similar words. 

The advantages of the rapid method are as fol- 
lows: 

i. Sure success, for by the isolation of the pa- 
tient, any hope of obtaining morphine is completely 
forestalled. 

2. Absolute security from danger, as by the ab- 
sence of collapse, the life of the patient is not im- 
periled. 



— 18 — 

3. A very short duration of the symptoms pro- 
duced by abstinence. 

4. Prolongation of the time for convalescence 
and restoration. 

I have not had occasion to observe any serious 
disadvantages in connection with this method. 

Burkart's experience, that those who take their 
morphine by the mouth are able to endure the effects 
of deprivation more easily than those who inject the 
alkaloid, agrees with my own. The symptoms in the 
first case are not so intensive or extensive as those of 
the second, although the morphine eaters (if I may 
use the expression) consume a far greater quantity of 
the narcotic than the morphine injectors. From this 
it would appear that it would be far better for mor- 
phinists to take their morphine by mouth. 



CHAPTER II. 

WHERE SHALL THE TREATMENT BE CON- 
DUCTED, AND WHAT ARE THE CONDI- 
TIONS OF ITS SUCCESS? 

Where shall the treatment be conducted? This is 
the question which has engaged the attention of phy- 
sicians ever since they have known anything about the 
morphine habit and the difficulties of curing it. Vari- 
ous and widely different answers have been given to 
this question, according to the ideas prevalent about 
the disease, and about the value of the different modes 
of withdrawal. 

On one point, only, all are agreed, viz., that the 
morphinist alone, in his domestic relations, in the ex- 
ercise of his calling, and without medical direction and 
help, is never able to break off his deplorable habit, 
and obtain self-mastery. The demand of the system 
for the accustomed stimulus, a craving which becomes 
the more imperious the more the habitual dose is less- 
ened, the pain and distress which follow the abstin- 
ence, will gradually overcome the strongest will; the 
patient after long struggling with the deep organic 
longings, and the nervous irritation and depression, 
yields to the temptation and falls again into bondage. 
There are exceptions to this rule, but they are 
exceedingly rare. In my practice of twelve years, I 
have known but three cases where self-cure was sue- 



cessful, but I have known of tenfold more instances 
of failures. Even with regard to those three patients, 
I am obliged to confess that they afterwards relapsed 
into their habit. 

One kind of home treatment deserves allusion to 
— it is a secret method of cure. A relative of the 
morphinist, perhaps a druggist, with kindly intent 
and with the co-operation of the family, though 
without the knowledge of the patient, will sometimes 
undertake to wean the victim of his habit by increas- 
ing the quantity of water in the morphine solution. 
This procedure deserves condemnation. It can never 
accomplish its purpose, but, on the contrary, may lead 
to ill-consequences. The dilution of the morphine 
solution is done arbitrarily and without judgment; if 
this thing is attempted as part of the treatment it 
ought to be done by a physician, and with due refer- 
ence to the condition of the patient. Moreover, 
there soon comes a time when the patient, by dint of 
the sufferings which he experiences, becomes con- 
vinced of the deception which is practised upon him, 
and he loses all confidence in his attendants; he then 
becomes unmanageable. After being kept for a time 
on the lessened doses, in his desperation he obtains 
clandestinely or openly a quantity of morphine, and 
returns to the doses which he had been before in the 
habit of taking; this is likely to prove too much for 
him in his present condition, and he may even ex- 
perience the symptoms of acute morphine poisoning. 
I have in fact known death to happen in this way. 



I can speak more favorably of another method of 
home treatment. The patient engages a physician, a 
medical expert, it may be, to be with him, and super- 
intend the administration and diminution of the doses. 

Older authorities who considered the morphine 
habit a psychosis, entertained the idea that an insane 
hospital was the only proper place for attempting a 
cure. The present generation of physicians think 
differently. It is only when the patient is suffer- 
ing from a complication of mental disturbances that 
the removal to a lunatic asylum is justifiable; or when 
the unfortunate morphinist, after repeated attempts at 
cure and continued falling back into the habit, re- 
quires a more prolonged treatment, of which a neces- 
sary part is a stricter surveillance and a restriction of 
liberty, all possibility of obtaining the drug being pre- 
cluded. If the morphine taker, by his own free will 
and request, wishes to enter an insane hospital for 
treatment, there can, of course, be no objection. Pa- 
tients addicted to morphine and cocaine habit who 
are suffering hallucinations and delusions, are proper 
subjects for the asylum, and should be at once sent 
there, and for several months. 

We must next bear in mind that as long as a mor- 
phinist is not mentally deranged, and his acts are not 
criminally or socially offensive, nobody has the right 
to compel him to abstinence. 

Exception must be made when a minor, or a per- 
son put under guardianship, is the victim. Here the 



parents or guardians have the right to exercise force. 
Otherwise, neither the husband, nor the wife, nor the 
father, nor the son, can compel the morphinist against 
his will to submit to the conditions of the cure, nor 
can one man compel his neighbor. Hence, in the ma- 
jority of cases, the transfer of the sick individual to a 
place for treatment depends not on the will of others, 
but on his own free will and accord. 

The choice of the place of cure is influenced by 
various circumstances: the recommendation of friends, 
of one's family physician, etc. Morphinists of both 
sexes are generally acquainted with the literature and 
history of the malady; each forms his own opinion as 
to the value of the different methods of treatment, and 
selects that in which he has the most confidence. 

I must here interject the observation, that it is all 
lost time and worse than useless for the patient to en- 
ter the various sanitary resorts, water-cure establish- 
ments, kinesotherapy institutes, institutes for nervous 
diseases, etc., with the intent to be cured of the habit; 
they cannot be under the supervision and restric- 
tions imperatively necessary for a thorough cure, but 
have too much freedom. A place where the gradual 
withdrawal method is practised without any restriction 
of the liberty of the patient, cannot be considered a 
proper place for successful treatment. 

Of course even when in such an institution as I 
have named, a strict surveillance as to the supply of 
morphine is kept up, a sure cure is not always realized. 



— 2 3 — 

It may not be possible absolutely to prevent bribery 
of the assistants, or the sympathetic but mischievous 
interference of friends or of other patients, who so far 
yield to the importunities of the morphinist as sur- 
reptitiously to provide him with his morphine. 

Taking all these things into consideration, I am 
of the opinion that the best place for the purpose in 
question is a Special Institute where there are the ap- 
propriate arrangements for watching the patient, for 
the restriction of his liberty, and for the carrying out 
of any desired method of morphine withdrawal. The 
furniture and fixtures of the rooms I have before 
alluded to; it may only be added that a pleasure 
ground around or adjacent to the premises, of course 
securely fenced in, is desirable. The patient is ad- 
mitted under written obligations, for a certain length 
of time, resigning all will of his own, and pledging 
obedience to the orders of the authority. He pays 
the fees in advance, and resigns all claim to restitution 
in case the treatment is not successful. Institutes with 
such regulations exist in England, and it is. desirable 
that they should be kept up in Germany. This is not 
only for the interest of the patients themselves, but 
of that of other institutes as well, which are thereby 
protected against applications from parties who after- 
wards would injure the reputation of the place. I 
would advise that no institute should accept more 
than ten patients at a time. 



— 2 4 — 
THE RULES FOR SUCCESS OF THE TREATMENT. 

These are such as are required by the institute, 
and are to be complied with by the relatives of the 
patient. Both physicians and relatives must work to- 
gether in harmony if a good result is obtained. The 
regulations which the institute is to maintain have 
been already stated in a previous chapter, and con- 
sists in: i, security against any possible supply of 
morphine, or other drugs, by the strictest search of 
the patient's clothing and other effects on entrance; 
2, providing against future supply by the confiscation 
of his money or other property; 3, the prohibition of 
all communication and correspondence with the out- 
side world; 4, great care in the choice of assistants 
and servants, and frequent change in the help during 
the time of treatment, so that the attendants shall not 
be tired out; 5, incessant watching of the patient and 
attention to his wants; 6, equipment of the sick room 
with suitable conveniences, bath-rooms and water- 
closets being easily accessible, etc. 

With such a complete and complicated apparatus 
for facilitating treatment, managed as well as human 
knowledge and ability will permit, failures should be 
rare. That part of this apparatus which is most to be 
distrusted is the cortege of waiters and attendants. I 
will not assert, however, that failure from this source 
very often happens. If the attendants prove untrust- 
worthy and false, the patient is lost. Despite the 
greatest care and circumspection, the physician may 



be deceived in the character of his assistants: These 
may be overcome in the stern execution of their duty 
by considerations pertaining to the patient's age, sex, 
education and social position, religion, etc. The nurse 
or attendant, if he be not firm in his conscientiousness, 
may yield to temptations of many kinds presented by 
the patient. Great promises of pecuniary reward are 
not, however, likely to prevail. My employees, at 
least, have not yielded to such temptations, and have 
voluntarily delivered to me promissory notes of pa- 
tients, and telegraphic money orders, thus refusing 
large pecuniary inducements. More dangerous are 
promises of lifelong employment, support, and even 
marriage. 

Such are some of the hindrances to cure, and they - 
are not always to be avoided. A careful selection of 
servants, who must be well paid, and who must con- 
stantly be reminded of the importance of their duties, 
can alone prevent mishaps, and leave you with a good 
conscience in case of failure. 

Another rule which I would rigidly enforce, is to 
refuse to take any patient who may need morphine for 
a certain suffering, and will not or cannot submit to 
the conditions of cure. 

Moreover, you must have a care to the patient's 
surroundings the first few days after completion of 
the cure. He will have communication with other 
people, and if the latter have any morphine in their 
possession he may again fall a victim to his old habit. 



— 26 — 

The happiest result I have ever witnessed in a very 
serious case was spoiled in this way. 

The relatives and friends of the morphinist must 
submit to the rules needful to bring about a cure; 
neglect or omission on their part will ensure a final 
wreck. It is Levinstein's lasting merit that he has 
called attention to this requirement, the importance of 
which his experience had taught him. 

The friends or family should be the first to dis- 
cover the sources of morphine supply and stop it by 
every means in their power, even by complaining to the 
magistrate of the illegal and injurious sale of the drug. 
Experience teaches that the morphine victim has 
usually more than one place of purchase of the 
morphia. Therefore we must not be content with the 
discovery of one dealer only. Then we must ferret 
out the accessories, for it is rare that the patient goes 
himself to the druggist, after the habit is known, as 
this is not agreeable to either party. The purchase is 
effected, either by confidential messengers, or by mail 
under various assumed names. The agents employed 
are often nearer to the family than one would naturally 
expect — in one instance it was the cook, in another 
the nurse, in still another, the husband of the patient. 
I once treated a young man who had already tried 
five or six different systems of cure, and always had 
a relapse afterwards, till I discovered that his wife was 
suppling him by sewing the morphine into the cloth- 
ing she sent to the hospital. 



— 27 — 

Thus the ways of smuggling are innumerable, 
and the utmost attention and vigilance must be exer- 
cised. 



CHAPTER III. 

SYMPTOM-TREATMENT DIRECTED TO THE 
CONSEQUENCES OF ABSTINENCE. 

The symptoms occurring during the treatment 
are the consequences of the discontinuance of a 
powerful drug to which the organism has become 
accustomed. They constitute the reaction, which 
occurs to a greater or less extent, no matter what 
method of leaving off is employed. The disappear- 
ance of these symptoms is only a question of time, but 
while they last, what can be done must be done to 
mitigate their severity. We- will consider in their 
order the various phenomena rendering a symptomatic 
therapy necessary. 

THE COLLAPSE. 

m This is the most dangerous of all symptoms 
resulting from the withdrawal. It demands a prompt 
and energetic treatment from the danger to life which 
attends it. It must not be forgotten that a case of 
collapse apparently very light may become severe and 
even fatal, therefore this symptom must be early and 
effectively met. Fortunately, there is always at hand 
a sovereign remedy which, taken at the proper time, 
will obviate all the danger of the collapse; 1 refer to 
morphine. 

As soon as the first symptoms: irregularity of the 



— 2 9 — 

pulse and respiration, pallor and lividity of the'skin and 
mucous membranes, feelings of faintness, make their 
appearance, an injection of 0.025 (i grain) of morphine 
is made. If after ten or twelve minutes the symptoms 
do not subside, or if others should develop, the same 
injection is repeated, and this may be done three or 
four times in succession. Other means, such as ether 
injections, are uncertain and unreliable. I repeat, 
you must not hesitate to resort to the morphine injec- 
tions on the least appearance of collapse. There is, 
moreover, a series of analeptic medicines to be em- 
ployed as adjuvants, viz., hot tea or coffee, alcoholic 
stimulants, as Cognac, port-wine, or champagne, be- 
sides cutaneous irritation, hot water applications over 
the abdomen, etc. 

In case the respiration should stop, faradization 
of the phrenic nerves should be attempted. When 
the danger has passed, the pulse and respiration are 
still to be watched for some time, especially during 
the sleep which usually follows the collapse. The 
severer symptoms, however, do not all make their ap- 
pearance if the morphine is injected early. 

DELIRIUM. 

The milder forms of delirium that appear during 
the slow method of withdrawal generally pass off with 
the use of alcoholic stimulants. For the maniacal 
delirium, however, two or three morphine injections 
may be required, especially when the excitement as- 



— 3° — 
sumes a dangerous aspect. Apart from this, the 
therapeutics of delirium tremens, such as large doses 
of chloral, paraldehyde, or opium, are also here appli- 
cable. 

ALCOHOLIC POISONING. 

I must call attention to a condition which may 
simulate a collapse, and which may happen to dis- 
obedient patients, or in consequence of the indulgence 
of too compliant nurses. I refer to alcoholic poisoning 
during abstinence. Patients who have been in the 
habit of taking alcoholic stimulants freely, try to avoid 
the painful effects of the abstinence symptoms by im- 
bibition of spirits. In spite of all warnings, they will 
drink wine, beer, cognac, alone or mixed, in too large 
quantities, while at the same time they neglect to take 
solid food. Suddenly they break down — lose conscious- 
ness and control of their members and the power of 
speech; the saliva drops from their mouth, the face 
flushes; the pulse, however, is frequent and full, and 
this marks the difference between this condition and 
a collapse. The treatment should be the administra- 
tion of emetics, and subsequently hot coffee and solid 
food. Patients addicted to alcoholic excesses have to 
pay the penalty of their transgressions. The state in 
which they find themselves the following day, when 
the misery of the morphinism and of the alcoholic ex- 
cesses come together, is pitiable in the highest degree. 



— 3 1 — 

VOMITING. 

Under the slow method this symptom sometimes 
appears, but is rarely severe and obstinate. It seldom 
lasts many days, and rarely demands medical atten- 
tion. Omit all food for a few hours, or confine the 
patient to milk or oatmeal gruel; give him small bits 
of ice. In very bad cases where the vomiting holds 
on for some time and interferes with the taking of food, 
morphine injections should be at once resorted to. 

If the patient be a female, it may be worth con- 
sideration whether she may not be pregnant. Vomit- 
ing on the last part of the first and during the second 
week of withdrawal is certainly not an abstinence 
symptom. Vomiting is the symptom which, as a rule, 
disappears first. I have known vomiting, by the way, 
to be caused by the administration of our German 
opiate tincture — tinctura opii crocata — for diarrhoea or 
belly ache. In such cases pure opium has had a good 
effect, or opium given otherwise than by the mouth. 

DIARRHCEA AND BELLY-ACHE. 

The first of these symptoms occurs in the case of 
nearly every patient. It makes its appearance toward 
the end of the withdrawal period, or one or two days 
after the last injection. It is to be regarded as rather 
salutary than injurious, and if it should not come on 
in due time a purgative is given to clear the prima 
via. Where the diarrhoea is absent, the patient's rest- 
lessness is greater. Therefore I take no pains on the 



— 32 — 

first and second day of the diarrhoea to stop it, unless 
it becomes excessive or causes painful sensations in 
the anus, or great tenesmus. The treatment is both 
dietetic and medicinal. For diet we give barley and 
flour gruel, rice and rice water, sago, toast, mutton 
tea, red wine, etc. Opium, of course, stands first 
among the medicines. But we often have patients ta 
whom narcotics in no form should be given; thus, we 
may have an opium-eater who has been weaned of his 
habit, and there is every reason for not using opium 
to allay the diarrhoea. There are also morphinists 
who quickly fall into the habit of resorting to opium, 
and who call for it constantly to check diarrhoea. In 
treating such patients I change the remedies often, 
and give narcotics only when belly-ache is com- 
plained of. 

When I feel constrained to avoid narcotics, I 
often give simple remedies such as a gramme (15 
grains) each, in powder, of salep and gum arabic, to 
be repeated every half-hour. Or sugar of lead and 
strychnine, as in the following prescription: 

IJ Acet. plumbi 0.4 (f grain). 

Tinct. strych 2.0 ( 3 ss). 

Aquae menth., pip 175.0 (§ v and 3 vi). 

Syrup acaciae. . . * 25.0 ( 3 vi). 

M. Sig. A tablespoonful every hour. 

To the latter medicine, one, two, three or more 
grammes of laudanum may be added. Tannin is also 
sometimes of service. 



— 33 — 

When I deem it necessary to allow narcotics, I 
give laudanum or crude opium; of the latter o.i (i-J- 
grains) per dose. This may be with advantage com- 
bined with subnitrate of bismuth in dose of i 
gramme (15 grains). 

For the abdominal colicky pain, warm moist poul- 
tices over the belly are generally efficacious. If this 
pain be connected with vomiting, I make a subcutane- 
ous injection of extract opii, 0.05 (-J- grain). 

Pains in the calf of the /eg, or drawing up of the 
limbs are often lessened by massage and friction, 
although this may increase them. 

General restlessness and sleeplessness are trouble- 
some symptoms, and should be attended to as quickly 
as possible. Their treatment is sometimes very diffi- 
cult. Before administering a soporific, you should be 
perfectly sure that the complaints of the patient are 
really well founded, and that he cannot indeed sleep. 
There are two reasons for this: First, there are invet- 
erate morphinists who will simulate everything, and 
even sleeplessness, only to obtain narcotics; secondly, 
there are others in whom the sensation of sleep is 
utterly wanting, and they say in good faith that they 
do not sleep when they do. Such patients I have 
often had. They complain and lament every morning 
that they did not close their eyes all night, or that 
they slept only for a few moments; but when a watch 
is set over them, they are astonished at being told 
that they have slept soundly six, seven, or more hours. 

4 FF 



— 34 — 

Yet they were utterly unconscious of having slept at 
all. These are mostly patients with overstrained 
nervous constitution. I have observed this condition 
repeatedly in neurasthenic cases, and, indeed, the state 
of morphinists in the second and third week after the 
withdrawal, has a certain similarity to neurasthenia. 

In former times I have protested and warned 
against the use of chloral, because, with other observ- 
ers, I have had the experience that it is apt to cause 
great excitement and even severe delirium when given 
in the period of abstinence. But later experience has 
led me to the conclusion that chloral is a most certain 
sleep-producer, when given under certain conditions. 
To give chloral alone and for the first time when the 
patient is just leaving off opium, is bad practice, and 
only to be condemned. The conditions, under which 
it may be useful and effective, are: — Generally, as an 
evening dose, after the patient has been taking 6 to 8 
grammes (90 to 120 grains) of bromides during the 
day. A dose of 2.5 to 3.5 grammes of chloral (33 to 
48 grains) will then bring about, after a brief period 
of excitement, a beneficial sleep of several hours. I 
ani in the habit of giving my patients during the after- 
noon three-fourths of a bottleful to a bottleful of my 
bromide water, each bottleful containing 10 grammes 
(150 grains), and in the evening 2.5 grammes (45 
grains) of chloral hydrate; if he is not asleep in half 
an hour, I give him 1.25 grammes (3j) more. 

Chloral also works well during the withdrawal 



— 35 — 
period while the patient is still receiving a small but 
greatly diminished dose of morphine. Thus, on the 
third or fourth evening of the reduction, if the full 
dose of chloral be given with the small morphine in- 
jection, a good result is likely to be obtained; the 
patient does not get enough morphine to excite him, 
and the chloral causes no excitement. So the last 
morphine given by mouth may. also be given along 
with chloral; chloral so administered is followed by 
no excitation. 

But unfortunately, chloral is not under all circum- 
stances a sure hypnotic. You will meet in your prac- 
tice severe cases — morphine injectors of many years 
standing, who have tried many " cures " to no effect; 
great physical and mental prostration has ensued, and 
chloral does no good. In such cases there remains 
nothing to do but to resort to morphine. I give, then, 
the alkaloid internally on two consecutive evenings; a 
certain cumulative effect takes place. The first night 
after the administration of the morphine by mouth in 
the dose of 0.025 (i grain) there is usually no sleep, 
but on the second night after giving the same dose, a 
sound sleep of six to eight hours duration will ensue. 
When this course is followed up once or twice a week 
for several weeks, it often brings about a good healthy 
condition in the patient, and it is no rare experience 
with me to find the repeated administration of these 
small doses of morphine for a short time result in 
such benefit and recuperation that it was soon possible 



— 36 — 

to stop it altogether. I have not observed any special 
danger from these resumed doses of morphine, 
although I feared it; but after I was constrained in 
several bad cases where every other medicine had 
failed, to resort to this, I was convinced that my fear 
was groundless. If any one prefers not to prescribe 
morphine he may try codeia in the same doses as 
morphia, but the effect is not so prompt and pleasant, 
for codeia has not the excitant action on the organism 
that morphine has. 

Urethan I have found to be utterly inefficacious. 
Paraldehyde is rejected by most patients, and is 
hardly suitable for administration on account of its 
abominable taste and smell. But even if it were 
acceptable to the patient, and well borne by the stom- 
ach, its hypnotic action is by no means sure. 

With sufficient sleep, the general restlessness in 
the daytime soon disappears. The best remedy is 
rest in bed. Generally, the patients do not like absolute 
rest, and prefer walking and riding. But we must 
not yield to this propensity, but keep them rigorously 
in bed, limit them to moderate quantities of alcohol, 
and in two or three days the desired quietude will be 
obtained. 

On the whole, the importance of quiet, rest in 
bed, and warmth in promoting restoration during the 
abstinence struggle, cannot be overestimated. I order 
every patient to bed at the start, and can state with 
confidence that those who submit to this till I allow a 



— 37 — 

change, will get along more easily and satisfactorily 
during the treatment than others who do not obey, 
but who insist on moving about, or having the run of 
the premises. 

A nourishing and strengthening diet is needed. 
As long as morphine is to be injected^ it is advisable 
that patients take as much nourishment as possible 
soon after the injection, for at that time they are dis- 
posed to take food, and in a fit condition to receive 
it. At the height of the abstinence period they refuse 
food, and especially meat. Then milk is tried, and 
all they will take is allowed. Alcoholic stimulants 
must not be spared; champagne, cognac, whisky and 
port wine, and strong beer are to be freely given. A 
great help in strengthening the patient is the bath — 
full warm baths of 27 R. (95 F., 35 C), for 15 to 
30 minutes. Begin with them early, if possible daily, 
or even twice a day. The sick experience after the 
bath a sense of bim-etre, and sleep for several hours. 
Of good effect after the warm bath are cold frictions 
and cold douches, but not many patients can endure 
them. Feeble patients are very sensitive to cold, and 
with such the cold water treatment must of course be 
avoided. Of great assistance in the abstinence period 
is fresh air, and I can not too highly recommend to 
bring the patient as soon as he can bear it for a few 
hours every day into the open air. If he can 
walk, let him go on foot, if not, take him out in an 
open carriage, of course under strict surveillance. 



- 38 - 

AVhen the physical condition will not allow his going 
out, keep him near an open window. Walking, and 
other bodily exercises, are often injurious at the period 
immediately following withdrawal; they are followed 
by fatigue, great restlessness and insomnia, even after 
these symptoms had almost entirely or quite disap- 
peared. 

Mental Disturbances appearing during treat- 
ment, or soon after its completion, are to be combated 
according to indications, and according to modern 
psychiatric doctrines. When the patient is under 
treatment in a lunatic asylum, or an institute where 
the director is possessed of psychiatric knowledge, 
then the treatment of the psychosis can go hand in 
hand with that of the abstinence. If he is being 
cared for at home, he should be at once consigned to 
a regular insane asylum. Before and during the re- 
removal of the patient to such an institution, he is to 
be guarded with the utmost care against impulsive 
acts of violence toward himself or his keepers. The 
possibility of such violent outbreaks should never be 
lost sight of, nor should the attendants be for a 
moment deceived by the apparently tranquil and 
good natured behavior of the sick person, who may at 
any moment become dangerous. If he is used to 
alcohol, let him have it freely. After complete with- 
drawal of and weaning from morphine, opium may be 
given in large doses. If cocaine has been employed, 
its use must be at once discontinued. In connection 



— 39 — 
with these measures, a nutritious diet and prolonged 
baths at the temperature indicated above are useful. 
During the bath, the greatest caution is of course 
necessary; the presence of one attendant only is not 
enough. 

Hysterical Manifestations must be attacked 
with energy. No heed is to be given to daily 
complaints, nor is the patient's realization of the 
malady to be fostered by over-care, rest in bed, and 
anxious inquiries and attentions. It were better to 
drive the patient from her bed, to compel her to see 
company, and, above all, to apply herself to some 
wholesome occupation. Many such patients thrive 
best under a sort of medical neglect, provided, of 
course, that the diagnosis of the hysterical condition is 
absolutely correct. 

Besides this psychiatric treatment, to which I 
attach great importance, I recommend a mild hydro- 
therapy treatment in the form of several daily rubs 
with wet cloths or sponges, the use of infusions of 
valerian with bromides, a nutritious diet, and exercise 
in the open air. If anaemia should be present, then I 
give along with an appropriate diet, iron or haemo- 
globin. For the relief of pain in the back, I try, gen- 
erally with success, electricity, or the application of 
tincture of iodine. 

Causal Sufferings. — During the final leaving 
off, in many patients those sufferings reappear which 
were the original cause of the morphine habit. I can- 



— 4 o — 

not here enter into all the details of treatment for such 
cases, but will only call attention to one point. Among 
these recurring causes for which morphine was origin- 
ally demanded, there are many kinds of pain for which, 
when all other remedies have failed, morphine injec- 
tions must be resorted to, and the sooner the better 
after the diagnosis is settled. What, for instance, can 
be the use of applying warm poultices, turpentine 
stupes, etc., or giving herb teas to a patient suffering 
from gall-stone colic ? If your diagnosis of this con- 
dition is certain, inject morphine at once; after the 
storm is over, rest follows, and the patient speedily 
recovers. But no morphine is to be given unless the diag- 
nosis be absolutely sure. Patients quickly observe that 
the physician is apt to be moved by complaints of 
great pain, of the real existence of which, of course, he 
cannot always be certain, and in their eagerness to 
obtain their accustomed injection of morphine, they 
feign the pain. Of course, we cannot be too much 
on our guard against the possibility of such shamming. 
Searching examinations have to be made; an unno- 
ticed pressure over the pretended seat of pain, an 
injection of aqua pura, after which the patient appears 
quiet, will reveal the simulation. On such occa- 
sions, the physician will be put to his wit's end, and 
there will be ample opportunity for the exercise of 
the most brilliant diagnostic powers. 

Such shamming, amounting to nothing less than 
open fraud, is likely to happen in connection with the 



— 41 — 
ordinary symptoms of abstinence. If the physician 
makes it a point to give opium for attacks of abdo- 
minal pain, these will recur with astonishing frequency, 
the diarrhoea will not abate, nor the pain cease. 

The treatment of " Secondary Abstinence Symp- 
toms " will come up under the head of Prevention of 
Relapse. 



CHAPTER IV 

THE COCAINE TREATMENT— ABUSE OF COCAINE 
—COCAINE HABIT. 

The use and abuse of cocaine in the treatment of 
morphiomania demand a special consideration in this 
place. 

This alkaloid has lately been loudly vaunted as a 
safe and certain remedy for the morphine habit. Not 
only medical journals, but the daily secular press have 
proclaimed its singular efficacy. A more calm and 
sober view of this pretention can now be had. It has 
been found that cocaine is comparatively of little 
service either as an antidote or substitute; abuse easily 
succeeds the use, and the last state is often worse 
than the first. 

The first recommendations to employ coca and 
cocaine in the treatment of morphinism came from the 
United States, and date from the year 1878. According 
to Freud, who reproduced many of the articles in the 
American medical journals, "the coca preparations 
possess the power of suppressing the craving for mor- 
phine in the morphiomaniac, and reduce the dangers 
of collapse to a minimum." During 1878 and 1879, 
sixteen successful cases of treatment were reported, 
and one failure. Since 1880, the American medical 
journals have had little or nothing to say about the 
cocaine cure, and Freud concludes that the method 



— 43 — 
had gone into general use, having triumphantly passed 
through the stage of discussion ! One might with as 
much propriety affirm that it had been abandoned on 
account of being found to be worthless. 

Freud, himself, had an opportunity to observe 
the effects of cocaine in the case of a patient treated 
by the sudden method of withdrawal. This man had 
previously suffered severely during an attempt to 
break off the habit. On the occasion above referred 
to, his condition was fairly good; there was no de- 
pression or nausea as long as the effects of the cocaine 
lasted; chills and diarrhoea were the only persistent 
symptoms. During treatment he remained out of bed 
and "active," and took the first few days three deci- 
grams (4^ grains) of muriate of cocaine daily; after 
ten days he was able to dispense with it altogether. 

From this meagre statement of the case, I cannot 
see the proof of the favorable effects of cocaine. Very 
many patients during the first trying days of abstin- 
ence are free from depression and nausea; persistent 
chills and diarrhoea are not so very common, even 
when the sudden method is carried out; if Freud's 
patient had these symptoms, he was hardly fit to be 
up and moving about. 

Freud adds, in explanation of the good effects of 
cocaine treatment, that cocaine, when prescribed after 
withdrawal, is not to be considered in the light of a 
substitute, for this would change the morphinist into a 
cocainist; he does not believe, moreover, that it is the 



— 44 — 
tonic properties of cocaine which, by invigorating the 
weak organism, enable the patient to better endure 
the symptoms following abstinence. "I am per- 
suaded," he says, "that it possesses a direct antago- 
nistic effect to morphine." In support of this view, 
he cites a case from the clinical observations of Dr. 
Joseph Pollack: 

" A lady, 33 years of age, suffered for years from 
an atrocious migraine, supervening at the menstrual 
epoch, and which could only be mitigated by mor- 
phine injections. Although she abstained from mor- 
phine when free from the malady, yet during the 
attacks she behaved like a morphiomaniac. A few 
hours after the injection there would be great depres- 
sion, nausea, and vomiting, which would cease with 
another injection, after which the symptoms of intol- 
erance were repeated. Now cocaine was given for 
the migraine, but proved useless. Morphine had to 
be resorted to again, but as the morphine symptoms 
returned, they were quickly mitigated by one deci 
gram (r| grain) of cocaine." 

I should interpret the case somewhat differently 
from Freud. If cocaine works effectually during sud- 
den suppression of morphine, and the collapse is re- 
duced to a minimum, then it must operate like mor- 
phine, and can only have a substitutional effect. The 
idea that it works antagonistically to morphine is 
erroneous, and can only come from mistaking abstin- 
ence symptoms for toxaemic symptoms. In Pollack's 



— 45 — 
patient, the symptoms of morphinism were removed as 
well by a repeated morphine injection as by a dose of 
cocaine, and the two medicaments evidentally acted 
in essentially the same way. I had occasion to verify 
this view of the case, as this very patient afterwards 
came to my clinic for treatment, and I had an oppor- 
tunity to study the case. 

Dr. Richter, of Pankow, in a paper read before 
the Society of Psychiatry December 8th, 1884, also 
defends the cocaine treatment of the abstinence symp- 
toms, and thinks that by hypodermics of cocaine he 
can avert the dangerous and often fatal symptoms 
which often attend discontinuance of morphine. 

In some of the trials made by Richter, the cocaine 
seemed to annihilate the effects of morphine; and 
this antidotal action was as apparent to him as any 
chemical experiment made and frequently repeated in 
the laboratory. 

This view is, then, that of a direct antagonism 
between cocaine and morphine. During the discus- 
sion which followed the above paper, Blumenthal 
warned against the use of cocaine by morphinists; he 
had injected one centigramme and had observed in- 
creased reflex excitement, loquacity, lack of muscular 
feeling, fainting, mydriasis, cold sweats and a very 
feeble pulse. He expected death every moment; after 
fifteen minutes the patient rallied. 

Dr. Wall also recommends cocaine as antidotal to 
morphine. He, however, confounds the symptoms of 



- 46 - 

abstinence from morphine and cocaine poisoning, and 
has no clear ideas on the subject; his explanations are 
fantastic and utterly devoid of scientific exactness. 

My own experiments on the effect of cocaine in 
the treatment of the morphine habit comprehend 236 
cases. i made use only of cocaine muriate, in- 
jecting subcutaneously an aqueous solution. I have 
not made any internal use of this alkaloid. I have 
given: 

92 injections, of each ... 0.03 

10 u " ... 0.05 

2 " " ... 0.06 

Of these 236 injections, 193 were of pure cocaine, 
and 43 of cocaine with morphine; in 

5 cases 0.035 morph: -j- 0.015 cocaine 

5 " 



9 injections, of each . 


. 0.005 


17 


. O.OI 


33 ' " • 


. 0.015 


73 


. 0.02 



17 

2 
I 
2 
I 
4 

6 



0.03 


"0.02 


0.025 


44 0.015 


0.02 " 


11 0015 


0.015 


" 0015 


O.OI " 


" 0.015 


0.015 


11 0.02 


0.015 " 


" 0.03 " 


0.02 " 


" 003 " 



I have not given subcutaneously larger doses 
than 0.06 (-i- grain), and the whole quantity thus ad- 
ministered during twelve hours has never exceeded 
0.1 (ingrains). 

Of the 236 injections 232 were used in cases — 



— 47 — 
eight in number — of inveterate morphinism (5 were 
men and three were women). Four injections were 
made for purposes of trial only, and on nervous 
patients not addicted to morphine habit, of these, 
three in doses of 0.01, and one in the dose of 0.03. 

The qualitative effect of the cocaine in morphin- 
ists was in all cases the same. The only difference in 
the symptoms was in their intensity, and this does not 
depend on the quantity; I have often found a stronger 
effect after small doses than after large ones. 

The results of my investigations are as follows: 

1. Cocaine in o. 1 (i£ grain) doses daily injected 
did not affect the cerebro-spinal system; there was no 
disturbance in the centres of voluntary movements, 
consciousness, or sensation; neither paralysis nor 
spasms ensued, nor did physical excitement, intoxica- 
tion or sleep result. 

2. Cocaine in doses of 0.005 (tV g ram ) an d above 
seemed to paralyze the vaso-motor centres. This was 
evidenced by frequency of the pulse, enlargement 
of the arteries, dicrotism, profuse perspiration, and 
increase of temperature. This effect was always very 
transient. 

The increase of the pulse beats commenced from 5 
to 7 minutes after the injection, and soon reached its 
maximum; after 15 or 20 minutes the pulse was again 
normal. The frequency increased by 16 to 24 beats 
per minute; the smallest increase I observed was 6, 
the highest, 30 beats per minute. This inert 



- 4 8 - 

pulse is the most regular symptom of the cocaine injection. 
Once only I did not observe this symptom. Where 
cocaine was given together with morphine, the pulsa- 
tions were continuously the same. Simultaneously 
with the beginning of the increase of pulse, the finger 
pressed on the radial felt distinctly an augmenta- 
tion of the artery, and a higher pulse wave which be- 
fore was low. The patient expressed a feeling of 
warmth in the stomach and about the forehead, and 
on the palms and the forehead szveat appeared. This 
last symptom is not constant. 

As to increase of temperature, I have not observed 
this after one dose of cocaine, no matter how large the 
dose might have been, but only when cocaine was ad- 
ministered for several days in succession. A patient 
who had taken for two days four doses of two cgs. 
(•J grain) and on the third day two doses of two cgs. 
of cocaine subcutaneously, showed a temperature of 
38.2 (100. 2 F.) in the afternoon of the third day. On 
the fourth day he received no cocaine, and the tem- 
perature (taken every 3 hours) did not rise above 37.8 

(99° F.). 

The 5th and 6th days, 0.075 to 0.08 (\]/i to i}4 
grains) of cocaine were given by injection and on the 
7th day 0.01 (■$- grain), and in the afternoon the tem- 
perature was again 38.1 (109 F.). The 8th without 
cocaine, the temperature was 37.7 (99.5° F.). The 
morphine dose was intentionally kept up in the same 
amount during those eight days, being injected at the 
same time. 



— 49 — 

Mydriasis was not observed in any of my cases. I 
might here remark that there is a marked similarity 
between the effects of cocaine and nitrite of amyl. 

3. Cocaine produced subjectively a feeling of 
warmth which was in part referred to the stomach, 
and was in part general. After a cocaine injection 
given when the stomach was empty, there was a dis- 
agreeable, almost painful sensation of pressure or 
cramp in the region of the stomach. When injections 
of 0.05 (one grain) were made, or smaller injections 
frequently repeated, there was considerable distress 
and faintness, lasting for some time. 

How does cocaine act with reference to the symp- 
toms incident to abstinence from morphine during the 
treatment of the morphine habit ? 

All my patients experienced after the injection, a 
sensation of warmth, and expressed themselves as 
feeling more comfortable and every way better. This 
improvement did not, however, last longer then from 
ten to twenty-five minutes. 

When cocaine was injected during the period of 
greatest distress from abstinence, when the patients 
were continually yawning or sneezing, when they were 
suffering from cramps in the calves of their legs, or pains 
in the abdomen, then I observed that all these symp- 
toms disappeared in a few minutes, although the rest- 
lessness rarely disappeared. But this was not invari- 
ably the case, sometimes the cocaine utterly failed. 
When the symptoms did abate, they, as a rule, returned 



— Sc- 
atter a short time. My patients have always noticed by 
this fugitive effect that it was not morphine which I had 
given them by injection, and those who had already 
had experience with cocaine were able to tell, almost 
without exception, after the injection, whether it was 
morphine or cocaine that was used. They affirmed 
that the euphoric (refreshing, comforting) effect of 
cocaine comes on later than that of morphine, and 
that the relief and quiet thereby obtained are of 
shorter duration. 

The action of cocaine during the period after 
complete withdrawal of the morphine (/. ^., in those 
terrible 6 to 8 days when morphine was entirely with- 
held), was absolutely nil. It had no effect on restless- 
ness and insomnia, and none at all on the loss of ap- 
petite and diarrhoea. 

A simultaneous injection of morphine and cocaine 
proved that on the whole the effect of the morphine 
was predominating, that is, if we could depend on the 
statements of the patients as to their feelings. When 
the proportion of cocaine was larger, the physiological 
effect was later and feebler than with morphine alone 
in the same dose. 

The pulse always rose in frequency after each 
combined injection, and the sphygmograph showed 
without exception the cocaine action. A direct an- 
tagonistic result, as Richter puts it, I have not ob- 
served, though I have watched for it. But when 
repeated simultaneous injections of the two alkaloids 



— 5 1 — 
are made, the morphine under such conditions, is as 
it were, kept in the background, the predominance of 
the cocaine being due, as will be shown later, to in- 
crease of the dose. One effect of more value, which 
seems to be due to cocaine, is the diminution of the 
necessity and craving for morphine. This is, how- 
ever, not constant, and seems to appear only after 
long continued cocaine treatment, and the simultane- 
ous rise in temperature. 

My own experience, which on the whole goes to 
confirm the first reports from America, is here sum- 
marized: 

i. Cocaine has the power to remove or "stave 
off" the so-called "abstinence symptoms" of the 
morphine treatment. 

2. The favorable effect of a single cocaine injec- 
tion is of very short duration, rarely exceeding 15 to 
25 minutes. 

3. Cocaine employed in the period of withdrawal 
is no antidote but a substitute for and of less value 
than morphine, as it is only qualitatively of equal 
effect, while this effect is very transient. 

4. Cocaine is not to be recommended in the 
treatment of the morphine habit, because its efficacy 
is of very short duration, and because of its paralyzing 
tendency it might, if its use were long continued, im- 
peril the heart and vascular system. 

The high cost of cocaine, which was formerly 
considered a serious drawback to its use, cannot now 
be regarded as an 6bjection. 



— 5 2 — 

I will only add that the few cocaine injections 
made in patients not addicted to the morphine habit 
resulted essentially in the same fugitive symptoms as 
observed above, viz., increase of pulse, sensation of 
warmth, fall of arterial pressure. Pupil and tempera- 
ture remained unaffected. 

Dr. Obersteiner, who had already, at the Interna- 
tional Medical Congress in Copenhagen in 1884, ad- 
vocated the use of cocaine in morphine abstinence, 
has again lately recommended this kind of treat- 
ment. He favors the internal administration of the 
cocaine, and says: " The best way is to give inter- 
nally 0.05 to 0.1 (-J- grain to 1^ grains) cocaine muri- 
ate in weak dilution — in about half a tumbler of water 
— from four to six times a day, as soon as the symp- 
toms of morphine hunger begin to become keen. The 
internal administration is greatly preferable to the 
subcutaneous; the refreshing, reviving and soothing 
effect appears with much more intensity than after the 
injection. Patients who just before were in wretch- 
edness and despair, tossing about in their beds, have 
said that they felt like new beings — a pleasant sen- 
sation of warmth pervaded them, and they could not 
have imagined that a medicine could possibly produce 
such a magic effect. This condition of well being 
lasts for a short time, disappearing in three to four 
hours, and if cocaine could do nothing but break the 
chain of physical and mental sufferings for periods 
of a few hours so as to make life endurable, it must 
be considered an invaluable medicine." 



— 53 — 

In this view Obersteiner would be certainly right 
if the same medicine were free from injurious after- 
effects. This acute and critical observer, indeed, 
recognized such effects in his own cases, and by an 
honest confession he has put a damper on his endorse- 
ment of the remedy. He states "that cocaine pro- 
duces insomnia, even after taking a medium dose, also 
sexual excitement; farther, that after repeated doses, 
often after a few days, vivid hallucinations of the sight 
and hearing would appear, and that this maybe the 
effect of a kind of intoxication." Finally, he is doubt- 
ful "whether a cure brought about by the long usage 
of cocaine would be the most desirable kind of a 
cure." 

Dr. Jaeckel is more euthusiastic and less cautious. 
He gives combined injections of morphine and co- 
caine, and finally leaves off the morphine and uses 
cocaine alone. " The consciousness," he says, " of not 
requiring morphine during the distressing abstinence 
symptoms is of itself enough to inspire the patients with 
courage, and they endure the sufferings more bravely 
and hopefully. The craving was very much lessened; 
they desired no combined injections, but preferred the 
cocaine alone." He seems quite unaware that his 
patients, whom he allows to go so far as to depend on 
their cocaine to put them in trim for company and 
dinner parties (!) are already victims of the cocaine 
habit, which in its turn must be broken off by no little 
suffering. 



— 54 — 

These communications, published prior to the 
fall of 1885, represent nearly all the German testimo- 
nies in favor of the cocaine treatment of morphio- 
mania. Early in 1886 appeared my own studies in 
relation to the cocaine habit, which was then almost 
unknown. After I had seen reason to reject cocaine, 
I found myself obliged to warn my colleagues against 
this dangerous remedy. My first preliminary com- 
munication was founded on thirteen observations which, 
in the course of two or three months, either as cases of 
my own or as consultation-cases, came to my knowl- 
edge, and the purport of this communication was to 
warn my associates in the treatment of morphinism to 
be chary in the use of subcutaneous injections of co- 
caine in this malady. 

The number of my cases, and the experimental 
data connected therewith, have so much increased, 
and so many approvals from others, in public and in 
private, have been received, that I can speak with still 
greater confidence and authority of the cocaine habit. 

There are two forms of cocaine habit: one where 
cocaine alone, and the other where cocaine and mor- 
phine together, are introduced into the organism. 
Both originate from the morphine habit; the man that 
becomes a cocainist has first been a morphinist. 
There are those who, as before said, become addicted 
to cocaine under the recommendation of physicians, 
and as a part of the system of treatment whereby it is 
sought to overcome the morphine habit. Then there 



— 55 — 
are the morphinists and opium-eaters who, after being 
already cured, take to cocaine, and give up one bond- 
age for another equally deplorable. The development 
of the cocaine habit often comes about most naturally. 
The morphinist begins, either alone or under medical 
guidance, to dishabituate himself to morphine by sub- 
stituting cocaine, and soon finds to his sorrow that he 
has cast out Satan by Beelzebub! Now the cocaine 
produces a reviving, exciting and strengthening — a so- 
called euphoric — effect. This is of short duration, but 
is again called forth by another injection, and so on. 
And the dose is gradually increased. Then the coca- 
ine and morphine are used together, the baneful effect 
of the latter outlasting the effect of the former, and 
making it necessary to resort to still larger doses of 
cocaine. Now the patient would gladly abstain from 
the use of the cocaine, but he cannot. The want of 
cocaine by the organism makes itself felt by various 
disagreeable, annoying sensations, which render him 
utterly unfit for work; he needs cocaine to put him in 
trim for business, and he is miserable without it; he 
has, in fact, the cocaine habit established. It is, more- 
over, a noticeable fact that relapses are much more 
likely to occur with the morphine-cocaine habit than 
where the individual has been under withdrawal treat- 
ment without cocaine, and the patient resorts not to 
morphine, but to cocaine. 

We note further, in connection with the develop- 
ment of cocainism, that cocaine operates very quickly 



- 56 - 

with destructive effect on both body and mind. To 
escape these disastrous results, the sufferer returns to 
morphine, and takes it together with his cocaine. He 
increases the dose of both, and often adds chloral or 
opium. I have often found patients using one, two 
or more grammes of morphine and one to three 
grammes of cocaine daily, and besides a few grammes 
of chloral in the evening! 

With regard to the symptoms of cocainism, I will 
divide them into toxaemic symptoms and abstinence 
symptoms, and will begin with the former. 

First, I must remark that the local irritation 
caused by the cocaine injections is considerable; hard 
nodules the size of a filbert often forming at the site 
of puncture, and remaining for months. 

I have proved by sphygmographic observations 
that the hypodermic use of cocaine produces a para- 
lyzing effect on the vascular system; it increases the 
frequency of the pulse, enfeebles the arterial and 
capillary system, causes dyspnoea and sweats. There 
are disturbances of the vaso-motors and respiration; 
fainting is sometimes a prominent symptom. All this 
testifies to the toxaemic effect of the cocaine. 

A rapid and marked loss of flesh is observed, 
especially when large doses are taken. Patients who 
had for years been used to morphine, and who had 
remained in a fair condition of general nutrition, lost 
at once in bodily weight — sometimes twenty to thirty 
per cent, in a few weeks — from the moment they be- 



— 57 — 
gan the cocaine habit with constantly increasing doses; 
this emaciation went on despite the fact of taking 
about the same amount of food as usual, and without 
any catarrh of the stomach to account for it. I have 
observed this progressive emaciation in patients using 
cocaine injections, who, to prevent the falling off in 
flesh and strength, were consuming an incredible 
amount of food. 

That continued vaso-motor paralysis is of great 
danger is evident enough; I must, therefore, emphati- 
cally warn you against the use of chloroform by 
cocaine habitues, as they will be likely to die in the 
anaesthesia of cardiac paralysis. 

The general appearance of the cocaine victim is 
worse than that of the morphiomaniac. The face has 
a pale and cadaverous look, the eyes are sunken in 
their sockets, the flesh is flabby. One patient told 
me that with the beginning of the cocaine habit he 
became utterly impotent. 

As for the effect of cocaine on the supreme nerv- 
ous centres, insomnia is one early and prominent 
symptom. This is usually the reason why morphine 
is resorted to, often with the addition of chloral. 

Highly destructive is the action of cocaine on the 
psychical nature. The severest symptom is the mental 
disturbance, which takes the form of insane hallucina- 
tions. The patient is the victim of the delirium of 
persecution. This develops very rapidly, and in a 
short time he breaks out in furious attacks on his 



- 58 - 

imaginary persecutors. Some, though not all, require 
transfer to an insane asylum. It may be affirmed 
that the greater part have hallucinations of vision and 
hearing, abnormal cutaneous irritations, general 
psychical weakness, loss of memory, and a sort of 
delusive feeling that they have been wronged. 

As regards the hallucinations of hearing, the 
patients claim to hear human voices insulting them, 
noises of all kinds, as of burglars and thieves breaking 
into the house, drums and trumpet signals, and war- 
cries, alarms of fire, etc. 

Hallucinations of Vision. — Besides the ordinary 
hallucinations pertaining to man and animals, there is 
one kind which seems almost like an optical defect. 
The patient sees on white surfaces numerous dark 
spots or points, so that the field of vision resembles a 
sieve. This I believe to be a multiple disseminated 
scotoma; the appearances are almost sure to be falsely 
interpreted by the patient. One woman got much ex- 
cited at seeing little holes in her parlor stove and 
thousands of fleas on her bed clothes. Nothing could 
convince her that this was merely an optical illusion. 
Another symptom of psychical aberration, very often 
observed, is an abnormal prolixity and diffusiveness 
in conversation and in correspondence. 

Cocainists talk and write in a sort of desultory, 
disconnected way; they never get through with what 
they have to say, and always have something to add, 
and are always repeating themselves. Some have a 



— 59 — 

mania for writing long letters with much inconse- 
quential prating; the consequence is that they never 
complete their duties — they work all day till late at 
night, and accomplish less than they could in a shorter 
time when free from cocaine. When such patients 
add loss of memory to their other mental weaknesses, 
conversation with them becomes absolutely painful. 

To those that endeavor to break off the habit, the 
abstinence symptoms are not manifold, and not 
violent. 

In the first place appear the vaso-motor and car- 
diac symptoms: palpitations, cardiosthenia, dyspnoea, 
and fainting fits. Their intensity is proportional to 
the quantity of the diminished dose and the rapidity of 
the withdrawal. That the fainting is a purely cocaine 
symptom, and not one of collapse, is proved by the 
fact that it occurs as a consequence of sudden with- 
drawal of the cocaine, even while morphine is given in 
undiminished doses at the same time. I have noticed 
the cocaine faintings repeatedly whilst the patient was 
still taking 0.5 (7-J- grains) morphine daily. Another 
and very important symptom is marked depression of 
the spirits, and great weakness of will-power. Such 
crying, whining, and complaining, such loss of energy 
and demoralization, and such a craving after excitants, 
as I have witnessed with most morphio-cocainists, 
I have not met with for years in the severest cases of 
morphiomania. 

This demoralization is of very long duration, and 



— 6o — 

is hence different from that of morphinists. The 
latter manifest, at the end of the treatment and when 
told that the last syringeful has been injected, a feel- 
ing of satisfaction and a certain moral elevation 
which is touching, they are grateful to their physician 
and attendants, even in the midst of their sufferings. 
It is not so with the cocaine victim, who takes no 
pleasure at the prospect of speedy deliverance; he 
keeps stupidly and incessantly crying after more 
cocaine, and is consequently always in danger of a re- 
lapse. 

The hallucinations of the special senses cease 
rapidly with the discontinuance of the cocaine, and 
almost simultaneously; so also does the mental con- 
fusion. The delirium of persecution, however, holds 
on for a long time, and makes itself apparent to the 
expert even when the patient denies it. Mistrust and 
jealousy characterize the conduct of the cocainist 
when in company with his fellows, and by their very 
irrationality betray the disease. 

The method of withdrawal may be sudden, if the 
dose of cocaine to which the patient has became 
habituated be not excessive, otherwise the slower 
method is better. Persons addicted to cocaine alone 
may take considerable quantities of alcohol, or some 
morphine internally. With morphio-cocainists, the 
dose of morphine remains unaltered during abstinence 
from cocaine. 

The prognosis of the morphio-cocaine habit is more 



— 6i — 

uncertain and more unfavorable than in the case of 
the morphine habit alone. In order to obtain lasting 
success, and immunity against relapse, the patient 
should be at once sent to some quiet secluded institute, 
where he shall be divested of all liberty and be con- 
stantly under the physician's eye and authority. 

This is a sorry picture which I have drawn of the 
disastrous effects of the cocaine habit, but I fear that 
I have not painted it darkly enough. Whoever has wit- 
nessed the rapid psychical and moral ruin which this 
cursed vice — for such it is — produces in a human 
being will not be likely to prescribe cocaine as a cure 
for morphinism. There is only one substance that can 
be compared with it in its devastating effects on the 
human constitution (and this is not so speedy in its 
action) — I refer to rum. 

Dr. Bornemann, of Wernegerode, has had similar 
experiences to my own, and has published in detail six 
cases. Some of these were characterized by " hallu- 
cinations of great vividness," leading to "an impulsive, 
insane state," which may result in homicide. One of 
these patients all at once fired a revolver from his 
window into the house of his best friend; another, a 
physician, ran suddenly around the asylum one night 
with a revolver " to shoot his persecutors. 

Drs. Seifert and Haupt report similar observa- 
tions. Smidt warns against the combined use of 
morphine and cocaine, and calls it a therapeutic blun- 
der. This statement decidedly reflects on Jaeckel, 



— 62 — 

who denounces the omission of the practice as "a vio- 
lation of professional duty." Westphal (Discussion at 
the Society of Physicians and Naturalists, Berlin) ob- 
served in a patient who, after long addiction to the 
morphine habit, had begun to inject cocaine, " an out- 
break of acute hallucinatory insanity." Jastrowitz had 
the same experience, and adds the " occurrence of 
excessive salivation," and "dryness of the mouth." 
Heimann believes in a " typical cocaine psychosis," 
and speaks of disagreeable cutaneous hallucinations, 
sensations of tickling, pinching, formication, of alter- 
nate cold and hot applications, feelings as of " electric 
shocks," etc. He is correct in his statement about the 
abnormal sensations of the skin. I must also agree 
with Heimann that after the cessation of cocaine, no 
new hallucinations appear, but that the delusions al- 
ready existing continue for a long time, and that coca- 
inists are great dissimulators. 



CHAPTER V. 

PREVENTION OF RELAPSE. 

With the complete discontinuance of the use of 
morphine, whatever method of cure may have been 
adopted, the treatment of chronic morphiomania is 
ended. But though entire abstinence is now endur- 
able, complete deliverance from the habit is not even 
yet obtained, and the patient is yet in danger of a 
relapse, which the physician is still earnestly interested 
in warding off. The withdrawal of the morphine is 
only a first step in a process which must be completed 
in the removal of the causes and prevention of a 
return. 

The causes of the habit must first be considered, 
before we can discuss the remedies to be applied. In 
the first place, all the many physical and mental states 
of pain and suffering must be ascertained which have 
withstood all other treatment and finally obliged the 
patient to have recourse to morphine. All these mor- 
bid states will reappear and assert their force during 
the progress of final abstinence, after the baneful alka- 
loid has been entirely eliminated from the organism. 

In the'second place, the craving for morphine has 
not been completely lost. Whether that craving began 
after long repeated injections, or whether it took hold 
of the patient with demoniacal power right after the 
first injection, it will manifest itself again and again 



— 6 4 - 

in full strength and unbridled manner when the 
patient is pronounced cured of the habit. 

A third cause of resumption of the habit consists 
in the slowness of those organic reparative changes 
which, in the way of compensation, attend the discon- 
tinuance of a powerful narcotic to the use of which 
the organism had so long adjusted itself. The physi- 
cal disturbances which follow the abstinence manifest 
themselves in the ratio of the length of time the habit 
has been kept up, and the doses employed; those who 
have been through several " cures " and have repeatedly 
fallen, are the worst subjects. Bear in mind that there 
is not only a poison to be eliminated, but there is, so to 
speak, a disequilibrated organism to be righted. In 
patients who have used morphine injections for ten or 
twelve years, or even longer, this troublesome dishar- 
mony, this maladjustment of the organism, may last 
for months. Hence, during this time, there is the 
craving for morphine, and the patient is liable to fall 
before temptation. 

Considerations based on the three above men- 
tioned causes must furnish the ground work and the 
leading indications for treatment. 

Successfully to meet indications derivable from 
the first of these causes, which may lead to a removal 
of the morphine habit, implies a thorough inquiry into 
the antecedents and present condition of the patient. 
The diagnosis must be rigidly exact, and it is by no 
means sufficient to say, for instance, that sciatica is the 



- 65 - 

cause of the morphiomania in this case, and insomnia 
in that; but it must be determined from what the 
sciatica proceeds, and from what the insomnia. Of 
course I do not pretend to recommend this as any 
thing new, for I know very well that a searching diag- 
nosis is the conditio sine qua non for successful therapy 
in all diseases, and especially in stubborn and chronic 
cases; this fact needs the more to be emphasized, as 
it is commonly neglected in the treatment of the mor- 
phine habit. It has been customary to consider this 
habit as a malady per se, as a primary disease, and 
from this false point of view, to treat it. On the con- 
trary, it is very necessary to understand that the mor- 
phine habit is a secondary affair, a consequence of in- 
firmity or disease whose successful treatment may 
accomplish more finally to emancipate the patient 
than the mere withdrawal of the morphine can do. 
To give in this place rules or directions for the diag- 
nosis is of course impossible. We might as well at- 
tempt to reproduce the lessons of diagnosis for all 
kinds of pathological conditions. 

As soon as the diagnosis is settled, the treatment 
must begin in good earnest and in the proper manner. 
If the attending physician have the proper means at 
hand for meeting the causal indications, he will not 
hesitate in their immediate application. If not, he 
will send the patient, just as soon as the condition of 
the latter will allow, to a proper institute. The patient 
is commended to some resident physician there, who 

6 FF 



— 66 — 

shall take special interest in the case, and communi- 
cate constantly with the physician before in charge. 
It not seldom happens that the causal disease must 
first be removed by an operation; this may be per- 
formed at the institute where the patient has been 
under treatment and broken of his habit, or the 
morphine may be withdrawn in the surgical wards 
after performance of the operation. A lady was under 
withdrawal treatment in accordance with my directions, 
though I had never seen her. Before taking her 
into our hospital, a painful gynecological trouble (a 
tumor) was ascertained to be the cause of the morph- 
ine habit, and I advised a surgical operation which 
should rid her of her uterine tumor before she put her- 
self under treatment. She went to the surgical clinic, 
was successfully operated upon, and was afterwards 
cured at the same place of her morphine habit. 

From the above, it will be seen that in some cases 
I favor a reversal of the usual course of treatment; 
thus, instead of abstinence and discontinuance of the 
habit first, then the treatment of the causal condition 
last, my latest experiences seem to indicate that under 
certain circumstances it is better to remove the orig- 
inal cause first, then wean from the morphine habit. 
An individual who in consequence of cholelithiasis 
(attacks of hepatic colic) became a morphinist, first 
went through a curative course for his malady at 
Carlsbad, and then successfully undertook at my in- 
stitute the cure of his morphine habit. Another 



_6 7 - 

patient who acquired the habit in consequence of suf- 
fering from subacute rheumatism, was first cured of 
his rheumatism at Nanheim, and afterwards of the 
morphinism with me. In both cases the cure was 
easily effected, as the original disease no longer ex- 
isted to aggravate the patient's craving for morphine. 

It is clear that this method is not applicable to 
cases of chronic disease, such as gout, tabes dorsalis, 
etc., but in practice there will be found a great many 
patients with whom it will be quite practicable; all 
persons, for instance, curable by a surgical operation, 
and those suffering from an acute inflammatory mal- 
ady. 

Naturally, we are here confronted by diseases 
that are incurable. Whatever we may do, no perman- 
ent success is possible. In such cases, there is also 
no security against a further demand for morphine, 
and a relapse cannot be prevented. On the contrary, 
the attending physician must, at the end of all his 
fruitless efforts, resort to morphine again, just to make 
existence tolerable to his patient. But even in these 
worst cases we ought to have these principles of treat- 
ment in view: First, to defer as long as possible the 
administration of morphine; second, to allow no one 
but the medical attendant to give morphine to the 
patient; finally, not to exceed the smallest dose that 
will give the desired relief. 

It will be seen from the above, that, while a direct 
therapy is recommended as alone likely to be success- 



— 6S — 

ful, the treatment of the habit and the craving can be 
for the most part only indirect. 

As with all passions, so with this one, the princi- 
pal aim must be to keep the patient free from tempta- 
tion. The longer and the more strictly this is effected, 
the greater will be the guarantee against a return to 
the habit. The danger of relapse is especially great 
directly after the first symptoms attending the with- 
drawal have passed off, and when the appetite is still 
vigorous. 

It is, therefore, dangerous to dismiss the patient 
from the hospital immediately after completion of the 
cure; he certainly ought to remain for several weeks 
longer under surveillance. During this time, his 
circumstances are to be so arranged that he may feel 
well physically and mentally, and free from despond- 
ent, gloomy thoughts. 

Walks, rides, social amusements, theatrical enter- 
tainments and concerts are all to be authorized, under 
reliable supervision of course. I am in the habit of 
sending for a relative or member of the family of the 
patient about eight or ten days after the " weaning" is 
over, both for the sake of company, and that the relative 
may assist in keeping a watch over the patient. The 
patients are very generally married, so the wife takes 
the role of companion and waiter after the completion 
of the withdrawal; she stays with him, accompanies 
him on his walks, and helps him to keep firm in his 
good resolutions not to yield again to temptation. 



- 69 - 

Three or four weeks are generally sufficient to remain 
in the institute; the sojourn may be longer than this, 
but should not be less. If the patient is obliged to 
resume immediately the duties of his business or voca- 
tion, which requires regular application and all his time, 
the return to the habit is almost certain. The constraint 
and tension inseparable from a right performance of 
the duties bring with them the greatest temptation, 
and my experience is that this is the rock on which 
most convalescents are wrecked. Whenever the cir- 
cumstances of the patient permit, he ought to go to a 
place of recreation, a summer resort, the seaside or 
the mountains, after leaving the special-institute. I 
prefer sending patients to the sea-side for invigoration 
and recuperation, and also because they are less liable 
to catch cold there. If the season be too severe for 
them to visit the north and east points of the coast to 
enjoy the invigorating baths there, I send them to 
some more southerly point. One thing is to be in- 
sisted on: the patient is not to lead an easy, indolent 
life, thinking to gain strength thereby, but his life 
should be so regulated as to give him plenty of 
physical exercise as well as rest. Especially should 
the resumption of mental activity be attended to at 
that time; it is immaterial whether this concerns his 
particular calling, or literary, artistic or other pursuits; 
the main requirement is the carrying out of a certain 
amount of systematic exercise within a set time. 
When the hour for work arrives, nothing should pre- 



— 7 o — 

vent the patient from attending to his duties till they 
are finished. Of course these tasks must be so regu- 
lated by the attending physician that no fatigue or 
exhaustion can result. By a careful attention to these 
matters two benefits are obtained; first, the ability for 
mental work makes itself soon felt, and then, by 
cultivating the sense of duty, the will and self control 
are strengthened, and the more he persists in these 
right endeavors and the better he succeeds, the more 
he elevates himself morally and intellectually, and the 
better able he is to cast off the dominion of his lower 
nature. 

At the patient's home everything should be so 
prepared and arranged that he may be spared any 
psychical impression or excitement that would tend to 
upset his self-control, and pains should be taken to 
keep from him everything that might remind him of 
his former vice. 

Levinstein used to advise the family of the patient 
to change the furniture of the house, or at least the 
place of the various articles, moving them into differ- 
ent rooms, if possible into another house; the bureaus 
or drawers where the patient formerly kept his mor- 
phine must be away, so that nothing may call his 
attention to his old habit. This is certainly advice 
worthy of consideration. 

When in this way the utmost possible time is de- 
voted to convalescence and reconstruction, a favorable 
result generally follows for five or six or more months. 



— yi — 

The patient feels physically well in every respect, and 
mentally fit for work; his general tone is cheerful and 
contented. Beyond six months this buoyant state 
rarely continues, and most relapses generally happen 
at this time. And what is the explanation of this fact ? 
The reason appears to be that the physical and mental 
forces of the patient are not yet enough restored to 
endure longer the strain of work. This is not to 
be wondered at if we consider, on the one hand, 
the volume and intensity of somatic and psychi- 
cal symptoms experienced during the period when 
the patient was under the poisoning influence of 
the drug, and, on the other hand, the mighty revolu- 
tion effected in the entire organism by the withdrawal 
The disturbed elements may be in great part equili- 
brated by the after treatment in the hospital or at the 
sea-side or hydropathic sanitarium, but the restoration 
lasts only for a brief period; the long persisting con- 
sequences of chronic morphine poisoning reappear as 
an overpowering inanition. A gastric catarrh, loss 
of appetite, dyspeptic troubles begin, with insomnia; 
the vital forces decline — the distress and weakness 
become unendurable. The patient remembers the 
magic power of the morphine of former times; he 
makes, with misgivings, the first injection, and if not 
more than two drops — no matter how small the quan- 
tity — the habit is reawakened, he is again its victim! 
In order to provide against the supervention of 
these " secondary abstinence symptoms," I deem it 



— 72 — 
very important to call the attention of the patient, on 
his leaving, the institute, to the dangers which beset his 
future, and what is required of him in order to avoid 
them. He must be made to understand that his re- 
covery is only limited and incomplete, and that he 
needs rest and quietude as soon as the first signs of 
enfeeblement appear. I recommend to him especially 
to consult a physician at such a time and to allow the 
latter, as a matter of course, a thorough insight into his 
previous habits and his physical and mental condition. 
In the case in question, there is only one remedy against 
a relapse, and that is, to stop at once all bodily and 
mental labor; no matter what his business may be, he 
must quit it. He must sequestrate himself from all 
cares and take a vacation in order to begin again a 
restorative course of treatment. A season of six 
months' recreation and recuperation after completion 
of the withdrawal is about the best remedy against a 
relapse. 

As for the treatment of the third cause of relapse, 
namely, when the physical disturbances fail to be 
compensated after withdrawal, owing to the long, 
deep-rooted persistence of the morphine habit, the 
following considerations seem called for: The organ- 
ism, as before said, has been for a long time, it may 
be for years, adjusted to the morphine excitation, and 
performs its functions in an abnormal and irregular 
manner without it. The patient, after the withdrawal, 
is left in such a condition of physical weakness and 



— 73 -*■ 
mental dilapidation as to be the victim of intolerable 
suffering, and unfit for enjoyment or application to 
work. He cannot sleep, he has no appetite, often 
vomits, and feels too much used up to rise from his 
bed. This condition continues for a long time, and 
grows worse from week to week. Various attempts at 
cure prove useless. Morphine is the only remedy. 
The best method is the one which I have pointed out 
before under the head of the treatment of insomnia; 
thereby we often succeed in obtaining an amelioration 
and an allaying of morbid conditions. When this end 
cannot be realized, and the patient leaves the estab- 
lishment, a relapse is certain to follow. It may often 
be necessary, before any improvement can be noted 
and the patient rendered fit to go home, to administer 
a full dose of morphine, and even then we must take 
care that the patient shall not give himself the injec- 
tion. It is understood, of course, that the attending 
physician shall prescribe the morphine in the smallest 
possible doses that will effect the desired result. 
Never lose your patience; I know of several cases 
where, after long temporary difficulties and discour- 
agements, an unexpected turn for the better took 
place. 



CHAPTER VI. 

GENERAL PREVENTION. 

The question whether it is possible to prevent the 
morphine habit, or, at least, to limit it, is one of great 
importance. Its significance is not only a scientific 
one, as the prophylaxis of a malady, which is the 
question before us, is surely a matter of scientific 
interest, but it is, above all, a subject pertaining to 
political economy. 

In answering this question, I do not give myself 
up to an illusive hope. I believe that the habit will 
not only remain as it is, but that it will grow worse 
from year to year. Levinstein, who has had so great 
an experience with cases of morphinism, (although when 
he made the remark he had not the insight which has 
been since then increasing for our benefit every year,) 
said ten years ago: " I do not believe myself deceived 
in the conviction that the morphine habit will be so 
far exterminated that it will, in the course of years, as 
contrasted with to-day, be very rarely known to exist/* 
How greatly he was mistaken, we to-day know very 
well, witnessing, as we do, the constant increase of 
morphinism. 

He based his assurance on the expectation of 
realizing certain conditions for fighting this disease 
which he looked to the government to enforce, and he 
made known the provisionary steps and propositions 



— 75 — 
which he had planned, and which he in due form sub- 
mitted to the proper authorities, in order to abate the 
nuisance, already then fast growing, of the illegal sale 
and delivery of morphine by druggists. His petition 
to the legislative body remained for the most part 
unnoticed, and when others again took it up, the 
" motion to consider " was quietly tabled. 

It is just so with the regulation of the abuse of 
ardent spirits, and it will require long, careful and 
earnest discussion before the only means which promises 
success will ever pass, namely, a high tax on distilled 
spirits, and free trade in light beers. And there might 
seem to be sufficient cause for the enactment of 
stringent laws, with heavy penalties, against dispensing 
morphine without a medical order, and against using 
the same order for a repeated supply. But I do not 
expect anything of the kind. I have complained of 
apothecaries where I had positive proof of the illegal 
delivery of morphine, but to no purpose. A year ago 
I entered a protest before the Minister of the Medical 
Department against the promiscuous sale of cocaine, 
with proof of its extremely dangerous and mind-de- 
stroying properties, but without success. It is no 
wonder, then, after such experiences, that I entertain 
very little hope of government aid in combating this 
ever-increasing malady of the better classes of society. 
From the apothecaries, moreover, no help can be ex- 
pected, as long as motives of greed overpower all 
considerations of moral honesty. 



_ 76 - 

There remain, therefore, only two ways of cir- 
cumventing the dire disease. 

The first is the exercise of the utmost painstaking 
care on the part of physicians in the administration of 
morphine, which should be given only in extreme 
emergency, and when employed in subcutaneous 
injections, should never be administered by any one 
but a physician. 

The other means of prevention is the diffusion 
among the people of sound information respecting 
this deplorable vice, and the promulgation of suitable 
warnings against it. 

Physicians cannot be too careful in prescribing 
the opium preparations, for under their advice and 
directions many a victim of the morphine habit takes 
the first downward step. Morphine ii hardly ever a 
remedial agent; it is only a symptom-meeting, stupefy- 
ing, narcotic palliative. The prescribing of this alka- 
loid often means nothing more nor less than a testi- 
monium pauperitatis of the diagnosis. Next to pre- 
vention, the ideal of treatment of any disease consists 
in aiming to compass the cause, and in the attain- 
ment of this object, morphine is almost never required. 
But how often this principle is violated ! How often 
is the internal and subcutaneous usage, of morphia 
carelessly prescribed! If physicians would exercise 
more care in this particular, and would rigidly abstain 
from ordering morphine except in rare emergencies, 
liability to the morphine habit would be materially 



— 77 — 
lessened. Therefore, I earnestly urge upon 'my col- 
leagues of the medical fraternity to order morphine 
only in cases of extreme necessity, and to give this 
dangerous narcotic no longer than it may be abso- 
lutely needed. Never should morphine be left with 
the patient to be administered by himself, and when 
its use is no longer required, the physician should 
deem it obligatory on himself to make sure that the 
patient does not clandestinely continue the use of the 
drug. 

Not only should the medical profession lift up 
its voice in warning, but the press ought earnestly 
to engage in the dissemination of such information as 
the general public needs; care of course being taken 
that contributions pertaining to the evils under con- 
sideration shall come from competent authorities, and 
not be merely a mask for the advertisements of 
quacks. The literature of morphinism in late years 
— I allude particularly to articles in various non- 
professional periodicals — teems with examples of what 
the press should not furnish to its readers. Inex- 
perience, and a desire to promulgate new but by no 
means tried and proved remedies and make known their 
effects, have been conspicuous in these lay-publica- 
tions, and as a consequence results have been realized 
which are far different from what would have attended 
the possession of sound information on the subject. 

The common people can hardly be expected to 
be interested in or even to understand medical works, 



- 7 8 - 

but if a chapter or two on the morphine vice could be 
treated in a popular manner by an expert pen and 
given to the general public, great good might ensue. 
In the same spirit the State might promulgate mes- 
sages of instruction and warning through its boards of 
health; and just as now the people are protected by- 
enactments against the use of poisonous dyes, against 
the adulteration of food, and against the abuse of 
ardent spirits, so in some way the government might 
manifest its reprobation of the deadly abuse of mor- 
phine. 



CHAPTER VII. 

REPORTS OF CASES. 

The following cases have been for the most part 
treated by my method of quick withdrawal. 

An essential part of the treatment is that the 
patient shall be kept by himself, watched and nursed 
day and night; he must also remain in bed. When 
able to walk or ride out, he is always accompanied by 
an attendant, His personal effects are taken from 
him, and the careful surveillance and nursing continues 
till he is virtually weaned. There is, of course, differ- 
erence among patients in this respect. One may need 
watching for only two or three days after the with- 
drawal, while another might need the same watching 
during the whole life time. 

I have only reported cases which were in my 
private hospital, and under my own care. 

CASE I. 

Morphine habit of two years duration; withdrawal 
in eight days; convalescence of twenty-seven days. 

Mr. Von H., officer, 27 years old. Cause: gall- 
stone colic; beginning in 1884. 

Actual daily dose, 0.3 (4^ grs.) morphine subcti- 
taneously. 

Symptoms of poisoning: constipation, sweating, 
abatement of sexual desire. 



— 8o — 

Presented himself for treatment June 17, 1886. 

He had taken 0.1 (i~y gr.). In the evening I 
gave him 0.05 (f gr.). 

June 18. Slept the whole night. Shall wait for 
the effects of the withdrawal to appear; 10:30 a. m., 
pulse 88, as he lies in bed; at noon, yawning and 
sneezing; 3:45 p. m., 0.05 (fy gr.); good day; has 
eaten well; 7 p. m., 0.05 (^ gr.); 10 p. m., pulse 72; 
up. m., 0.05 (% gr.). Whole amount taken during 
the day, 0.15 (2% grs.). 

June 19. Slept the whole night; 10:30 a. m., 

0.04(1 g^); 5 p - M -> °-°3 (% g r -); IJ p - M -i °-°3 {% 
gr.); whole amount 0.1 (\ 2 /z gr.). 

June 20. Slept soundly from 12 to 6 a. m., after- 
wards yawning and slight aneasiness; 9 a. m., 0.03 (% 
gr.); 3 p. m., 0.03 ( l / 2 gr.); 9 p. m., 0.03 (y 2 gr.); 
whole amount 0.09 (iy gr.). 

The patient progressed well. He read much, 
wrote a letter, and smoked. Contented frame of mind. 
Pulse steady strong and regular. 

June 21. Slept from 12 to 7 a. m. without awak- 
ening; 8:30 A. m., 0.02 (}i gr.); 3 p. m., 0.02 (ys gr.); 
7 p. m., 0.02 (ys gr.); whole amount 0.06 (1 gr.); con- 
dition as yesterday. 

June 22. Slept soundly from 11530 to 2:30 a. m., 
then tossed uneasily to and fro, often awake. In the 
morning, twinges of pain in the legs; 8:30 a. m., 0.01 
(H g r -); I2: 3° p - m., 0.01 (ye gr.); 6 p. m., o.oi (}& 
gr.); a bath; 11:45 p. m., o.oi (}£ gr.); whole amount 



— 81 — 

0.04 (Yz gr.). On the whole was in a contented frame 
of mind. 

June 23. Slept three hours; toward morning, 
uneasiness and pain in the calves of the legs; 8:30 
a. m., 0.01 {yt gr.); slight effect of the withdrawal; 
4:30 p.m., said he was much less uneasy than yesterday; 
ate with an appetite; smoked no more; 12 p.m., 0.0 i 
{Ye gr.); whole amount, 0.05 (y 2 gr.). 

June 24. Two hours' sound sleep; later, lay quiet; 
8:30 p. m., 0.01 (}£ gr.); 4 p. m., o.oi (}£ gr.) 12 p. m., 
°-°°75 (i + g r 0; whole amount, 0.0275 (f gr.). 

June 25. Slept well five hours; 8:30 a. m., 0.005 
(iV gr.) 1:30 p. m., 0.005 (A § r -)- During the after- 
noon walked in the garden; bath; tip. m., 0.0075 
(9 + g r 0; whole amount, 0.0175 (^ gr.). 

June 26. Slept four hours; felt well; break- 
fasted with appetite; in the garden. During the day, 
a bottle of bromine water; 10.0 ( 3 iiss). In the even- 
ing, 2.5 (37 grs.) chloral hydrate with 0.02 (ys gr.) 
morphia by the mouth. 

June 27. Slept seven hours; good day; much 
in the garden; sneezing occurred off and on for the 
first time to-day, also dragging pain in the legs; good 
appetite; diarrhoea once; a bottle of bromine water. 
In the evening, 2.5 (37 grs.) chloral without the mor- 
phia. 

June 28. Slept intermittently, but in the mean- 
while lay quietly; felt very well. In the evening, 0.12 
( T i g r -) opium. 



— 82 — 

June 29. Slept very well. In the evening, 0.06 
(?o £ r -) opium. 

July 5. Had no narcotic for three days; in a 
good condition. 

July 10. Drank rather too much wine and beer. 

July 22. Left in very good condition and with 
an^increase in weight of four pounds. 

In patients who are accustomed to smoking, their 
desire for it is a good barometer of their condition 
during the withdrawal treatment; as long as they 
relish their cigar, so long is their condition satisfac- 
tory. If, on the other hand, they do not wish to 
smoke, the influence of the morphine withdrawal is 
strongly manifest. 

CASE 11. 

Morphine habit of three years' duration. With- 
drawal in nine days. Convalescence of 35 days. 

Miss L., governess, 28 years old. Cause, peri- 
tonitis; beginning three years ago. 

She had obtained the morphia from Belgium, 
paying 20 marks per gramme, a quantity which lasted 
only a month, which made 1. gramme (15 grains) per 
day. But the other statements of the patient did not 
agree with this estimate of the amount. She had been 
in the habit of making a solution according to her 
judgment, and from this solution would inject daily 
6 to 8 syringefuls. It is assumed that if she had made 
the strongest possible solution (1 to 20), she would in- 



_ 8 3 - 

ject with the 8 syringefuls 8 times 0.05 (^ gr.) = 0.4 
(6 gr.) of morphia a day. 

Presented herself for treatment Nov. 28, 1888. 

Condition: Large, powerful frame; emaciated; 
weight 130 pounds; hollow-eyed; pale face; bad teeth. 
The teeth, excellent before, became, while taking 
the morphia, loose and carious. The patient could 
with the finger nails break off the enamel. Menses 
stopped about 1% years ago. 

Nov. 29. Gave 0.35 (5^ gr.) morphia. Patient 
slept very well. 

Nov. 30. Gave 0.25 (3^ gr.) Slept very well. 
No symptoms of the withdrawal. The statement of 
the daily dose of 1. (15 gr.) must have been false. 

Dec. 1. 0.15 (2% gr.) Slept little. During 
afternoon uneasy. Both yawning and sneezing. 

Dec. 2. Slept through the night. Toward 
morning, yawning and nausea. Ate little. Pale. 
Weight in the legs. Much sneezing. Much running 
from nose. Tears flowed. 10:30 p. m., very uneasy. 
Whole amount, 0.125 i 1 ^ & rs -)- 

Dec. 3. Slept very little. Pain in the back, 
dragging pain in thighs and legs. In the morning, 
uneasy, anxious; yawned and sneezed. Toward noon 
she became quiet; desired a bath. After that, menses 
began, with strong colicky pains. Twice, 15 drops of 
laudanum. In the evening, ate with appetite. Whole 
amount, 0.065 (* & r -)« 

Dec. 4. Slept only toward morning, from 4 to 7 



- 8 4 - 

a. m. On the whole, quiet during the night, as long 
as there was no pain in the bowels. Twice, 15 drops 
of laudanum. Ate pretty well. Drank a little 
more alcohol. In the afternoon slept well for two 
hours; during sleep frequent moving of arms and 
legs. Whole amount, 0.065 (* & r )• 

Dec. 5. Did not sleep; very excited. Repeated- 
ly loud moaning. Vomited. Drank very much milk. 
Pulse 80, always regular. During forenoon very ex- 
cited. Wept and groaned. Diarrhoea and vomiting. 
During afternoon more quiet. About 9:15 in the 
evening very excited, then again more quiet. Whole 
amount, 0.04 ( T 7 T gr.). 

Dec. 6. Slept from 1 to 5 a. m. During fore- 
noon desired to eat; much more quiet than yesterday. 
Drank milk a good deal. Return of pain in the 
bowels. Upon pressure, felt pain in the left ovary. 
Menses sparingly. Whole amount, 0.035 (y 2 gr.). 

Dec. 7. Quiet during the night; slept several 
hours. Expressed much joy at the annoucement that 
the withdrawal is at an end. Ate with enjoyment. 
Menses ceased. Evening, 0.0 1 (\ gr.). 

Dec. 8. Slept for hours. Forenoon, after break- 
fast, vomited. In other respects the day was passed 
contentedly. 

Dec. 9. Slept pretty well. Pain in bowels. Feared 
inflammation of the bowels again. Temperature 37. 6° 
C. (99. 6° F.). Infus. rhei with tinct. opii croe. Bath. 

Dec. 10. Slept well; pains gone; tongue still 
coated. Abstinence symptoms inconspicuous. 



- 8 S - 

Dec. 14. Contented condition. Pulse always 
100 to no. 

Dec. 25. Convalescing very well; face still pale. 
Dec. 31. Sleep and appetite normal. 
Jan. 11, 1883. Went home in very good condi- 
tion. 

Weight Dec. n 127 lbs. 

Dec. 19 131 " 

Dec. 25 135 '•* 

Jan. 1 137 " 

Jan. 8 138 " 

An increase of 1 1 pounds after the withdrawal. 
According to the last news, of the autumn of 1886, 
she has remained healthy and has not had a relapse. 

CASE III. 

Morphine habit of one years duration. First with- 
drawal in four days. Second withdrawal in seven days. 
Relapse. 

Dr. S., physician, 29 years old. 

Cause: Right supra-orbital neuralgia. 

Actual daily dose 1.0 (15 gr.) morphia subcut. 

No symptoms of poisoning worthy of note. 

Presented himself July 22, 1884. 

FIRST WITHDRAWAL. 

Condition: Heart all right. 
July 22. First day 0.33 (5 gr.). 
July 23. Slept well; dragging pain in calves of 
legs; yawning; bath. 



— 86 — 

Second day 0.12 (i|- gr.). 

July 24. Slept soundly 4 hours; yawning; bath. 

Third day 0.09 (i-J- gr.). 

July 25. Good night; dragging pain in calves of 
legs; yawning; sneezing; bath; went to ride; no special 
abstinence symptoms. 

No desire; fourth day 0.06 ( T 9 7 gr.). 

July 26. Slept the whole night; no abstinence 
symptoms; bath. 

July 27. Diarrhoea; 25 drops tinct. opii; good 
condition; bath. 

July 28. In company rode to the Niederwald- 
denkmai. 

July 31. Departed in excellent condition. 

Patient remained without opium until autumn. 
Then a relapse, partly from physical causes (supra- 
orbital neuralgia), partly from psychical reasons. He 
had increased the daily dose gradually up to 1.0 (15 
gr.). Had several times less'ened the dose, at one 
time to 0.03 ( T 6 y gr.). He could never do entirely 
without it. 

SECOND WITHDRAWAL, IN SEVEN DAYS. 

Entered Aug. 29, 1885. 

Had been taking daily doses of 0.5 to o. 6 (7-^ to 
9 gr.) of morphine subcut. 

Aug. 30. Slept the whole night. 

Last injection was made yesterday afternoon upon 
the journey. 1 p. m. o.i (r^ gr.), 11 p. m. o.i (i|gr.); 
bath in the afternoon; whole amount 0.2 (3 gr.). 



- 87 - 
Aug. 31. Slept the whole night; appetite;' smoked; 
contented; off and on, yawning and sneezing. 1 p. m. 
0.05 (fgr.); 11 p. m. 0.05 (fgr.); whole amount, 0.1 

(1* gr.)- 

Sept. i. Fell asleep first toward 12 a. m., then 

slept soundly until 7 a. m.; very cheerful; no abstin- 
ence symptoms. At 1 p. m., 0.05 (f gr.); for half an 
hour previously, very uneasy; eating well; afternoon 
and evening passed comfortably; 11 p. m. 0.05 (f gr.); 
whole amount 0.1 (i-J gr.). 

Sept. 2. Slept without interruption; breakfasted 
well; 10 a. m. 0.03 (^3 gr.); appetite continued; after- 
noon in the garden; dragging pains in the calves; 5 p. 
m. 0.02 (-J- gr.); quiet during the evening; at 8 p. m., 
tried to sleep but failed; whole amount 0.05 (f gr.). 

Sept. 3. Slept from 10 to 12 and from 1 to 2 a. 
m. uneasy; 3 a. m. 0.03 (^ gr.); then slept until 7 a. 
m.; got up very contented; feels well; appetite; bath; 
12:15 p. m. 0.02 (-J gr.); 8:30 p. m., 0.02 (^ gr.) whole 
amount 0.07 (1 gr.). 

Sept. 4. Slept soundly from 12 to 7; 9 a. m., 
pulse 60; 10 a. m., 0.02; good day; ate well; went 
to walk; evening temp. 37. 2 (98. 9 F.); whole amount 
0.02 ( T \ gr.). 

Sept; 5. Slept from 11:30 p. m. to 4 a. m.; 4:30 
a. m. 0.01 (1 gr.); 8 a. m. diarrhoea; 9 a. m., 25 drops 
laudanum; afternoon walked for 2 hours; smoked; 
ate well; whole amount 0.0 1 (i gr.). 

Sept. 6. Slept from 10:30 until 6 a. m.; in the 



— 88 — 

forenoon walked 2 hours; return of diarrhoea; 20 
drops laudanum; 2:30 p. m., severe acute neuralgia of 
the right supra-maxillary nerve; the teeth are not 
painful; can press the jaws together without increas- 
ing the pain. Cause: Patient has sat before an open 
window in a draught. Ordered: Galvanism. 

^ Salicylate of soda 10. (150 gr.). 
Tinct. gelsem., 10. (150 gr.). 
Aqua menth., 200. ( § visa). 

One teaspoonful hourly. Packing of salicylic cotton to 
face. 

Pains abated toward 10 p. m. 

Sept. 7. Slept the entire night; pain gone this 
morning. 

Sept. 10. Went home in very good condition. 
Has again had a relapse. 

CASE IV. 

Morphine habit of one and one-half years duration. 
Daily quantity, 1 gramme (15 grs.) to 1.5 grammes {22 
grs.) Withdrawal in 6 days. Convalescence of 20 days. 

Mr. W., student of medicine, 23 years old. Cause, 
enteritis, attack of cholera nostras. Habit began 1% 
years ago: His father, a physician, had made the first 
injection; which was quickly increased up to 2.0 (30 
grs.) of morphia subcut. daily. 

No special toxaemic symptoms, except abate- 
ment of sexual appetite. Entered for treatment Oct. 
1, 1881, 4 P. M. 



- 8 9 - 

Condition : Weight, 157 pounds; everything in 
order; heart intact; patellar reflex normal; urine free 
from albumen. Yesterday he had taken only 1.0 

(iS grs.)- 

Oct. 1. Has himself taken 0.25 (3fgrs.); re- 
ceived from me 0.025 + °-° 2 S (f £ r - + f & r -); whole 
amount, 0.3 (4-| gr.). Toward evening, yawning. 
Vomited once. 

Oct. 2. Some hours' sleep. Diarrhoea in the 
morning. Dragging pains in the calves. 6:30 a. m., 

°-°5-(K & r -); T p - M -> °-° 2 5 (f £ r -); 7 P- m., 0.025 (f 
gr.); 9 p. m., 0.05 (f gr.). Headache; no appetite; 
repeated vomiting. Bath. Whole amount, 0.15 (2-^- 
grs.). 1 100 c. c. (2f pints) of urine in 24 hours 
with strongly acid reaction, no albumen. 

Oct. 3. Slept from 10 p. m. to 4 a. m. Pollution; 
nausea and choking. Bath. 7:30 a. m., 0.035 (i& r -)j 
1 p. m., 0.01 (£ gr.); 7 p. m., 0.025 (f gr.); 10 p. m., 
0.015 (-^gr.). Whole amount, 0.085 (i^gr.) Has eaten 
pretty well. Pulse steady, regular, and full; 88 to 96. 

Oct. 4. 12:30 a. m., 0.015 (i & r -) ; after that 
slept until 5:15 a. m. Uneasy; vomiting; diarrhoea; 
headache. 8 a. m., 0.025 (f & r -)- Bath, if hours' 
sleep. 3 p. m., 0.01 (1 gr.). Bath. 7:30 p. m., 0.0 i 
(■i- gr.). Better .day than yesterday. Whole amount, 
0.06 (If gr.). 

Oct. 5. Slept from 11 to 12:30, 2 to 2:30 a. m., 
5:45 to 7:15 a. m. At 1:30 a. m., 0.0 1 (J gr.); S a.m.. 
0.01 (-i- gr.). Bath. Nausea; diarrhoea. Pulse, 96 to 



— 9 o — 

ioo. i p. m., 0.005 (tV £ r -)- ^ n tne afternoon, on 
account of diarrhoea, 10 drops of laudanum, which he 
threw up. 8:30 p. m., vomiting. 9 p. m., 0.005 (tV 
gr.). Whole amount, 0.03 ( T 6 ^- gr.). 

Oct. 6. Slept only twice, half an hour at each 
time. 1 a. m., 0.005 (tV & r -); 7 a. m., 0.005 (tV g r -)- 
At noon cried loudly for morphia. The categorical 
declaration that he should have no more, quieted him, 
and after a short time there was an alteration in his 
tone; great joy over the end of the withdrawal; 
desired to eat; ate even with appetite, but it was 
vomited. Bath. In the evening, 10 drops of lauda- 
num, which he vomited. Whole amount, 0.01 (-J- gr.). 

Oct. 7. Slept but little, but lay quietly. Milk was 
vomited. 7:30 a. m., bath. Before noon walked with 
me half an hour in the garden, which refreshed and 
tired him. Weight, 146 pounds (lost 11 pounds). He 
ate something; after that had three hours' sound, 
sleep. Very cheerful; desired to smoke. Evening, 2.5 
(38 g r -) chloral. 

Oct. 8. Excited at first, after the chloral last 
night; then slept soundly from 12 to 3 a. m., and from 4 
to 7 a. m. During the day, much in the garden. Has 
eaten enough. Bath. Evening 2.0 (30 gr.) chloral. 

Oct. 9. Slept several hours. Recovered very 
quickly. Developed a good appetite. No more diar- 
rhoea. Two baths. 

Oct. 10. Seven hours' sleep without chloral. 
Ate well. 



— 9 i — 

Oct. 14. Weight, 152 pounds. 

Oct. 20. Weight, 155 pounds. 

Oct. 27. Went home in excellent condition. 
Looked very well. Weight, 159 pounds. No longing 
for drink. Heart in order. Pulse not over 80. 

The vomiting occurring so often on the first day, 
was proof that the statement of the patient, that he 
had injected only 1.0 (15 gr.), was false; he had taken 
more than twice that. 

. The case is a very good voucher for the method. 
In six days, rapid withdrawal of 1.5 (22 grs.), perhaps 
even 2.0 (30 grs.). Severe symptoms, but very quiet 
and complete recovery in the 20 days the patient re- 
mained in the institute. 

case v. 

Morphia habit of three years duration. With- 
drawal in 5 days. Convalescence of 75 days. 

Mr. B., officer, 32 years old. 

Cause: Fracture of lower part of femur com- 
plicated with severe pain and sleeplessness. 

Bed-ridden 13 months; beginning 3 years ago. 

Actual daily dose 0.25 (3% grs.). 

Morphia subcut. In the last few days, (during 
the journey), somewhat more. Of the poisoning symp- 
toms are to be mentioned sweating, and falling out of 
the teeth. 

Condition: Everything normal. Weight 157 
pounds. 



— 9 2 — 

Entered for treatment Dec. 22, 1883. Had taken 
on the way 0.15 (2^ grs.). 

Dec. 2$. 10 a. m., 0.03 ( T 6 3- gr.). 6 p. m., 0.03 
(A £ r -)- II: 3° p - M -> °-°3 (A & r -)- Has eaten well. 
No appearance of abstinence symptoms. Bath. 1st 
day: 0.09 (|| grs.). 

Dec. 24. 9 a. m., 0.02, (i gr.). 5 p. m., 0.02 
(i & r -)- r J : 3° p - m j °-° 2 (i £ r -)- Slept 4 hours. Feels 
entirely well. Ate with appetite Smoked much. 
Drank moderately. At one time sneezing and yawn- 
ing. Second day, 0.06 (1 gr.). 

Dec. 25. 9 a. m., 0.01 (1 gr.). 5 p. m., o.oi 
(•J- gr.). 11:30 p. m., 0.01 (I gr.). Slept several hours. 
Out of bed. Read; wrote a letter. Assisted an- 
other patient who was undergoing the treatment with 
him. Toward evening uneasy. Vomited. Whining 
voice. Strong sneezing. Cold in the head. Third 
day 0.03 (| gr.). 

Dec. 26. 9 a. m. 0.005 (iV & r -)- S p - M -> °- 00 5 
(rs & r -)- IT: 3° p. m., 0.005 (ti g r -)- Slept little. 
Very uneasy. Diarrhoea, felt weak. Vomited. Pulse 
always good, 72. Fourth day 0.015 (A g r -)- 

Dec. 27. Slept little. 8 a. m., 0.0025 (^ gr.). 
Profuse diarrhoea with pain in the bowels, twice, 15 
drops of laudanum in an hour's interval. Bath. Pain 
in calves. Fifth day: 0.0025 (^ gr.). 

Dec. 28. Slept several hours. Pulse 100. Felt 
well; out of bed. Tongue coated. No appetite. 
Jan. 4. Pulse 88. Recovered rapidly. Daily, out of 



— 93 — 
doors, partly walking, partly driving. Slept well. 
Weight 154 lbs. Always diarrhoea. 

Jan. 7. Diarrhoea stopped Very strong appetite 
developed. 

Jan. 8. Weight 156 lbs. 

11. Went home in very good condition. 

Patient had only 28 days leave of absence, of 
these, 4-5 days consumed by the journey. The with- 
drawal was obliged to be hastened. 

CASE VI. 

Morphia habit of 6 years duration. Withdrawal 
in 8 days. Convalescence of 37 days. Frequent pollu- 
tions during the withdrawal. Four months after the with- 
drawal, gastric catarrh with weakness, uneasiness and 
sleeplessness. Quick recovery by means of opium. 

Dr. H., teacher in the gymnasium, 46 years old, 
unmarried. .Cause: gastric cramps and asthma; be- 
ginning 6 years ago. Was suffering from the following 
troubles: gastric catarrh; emaciation; falling of hair 
and teeth; loss of power; sleeplessness; loss of mem- 
ory; loss of will-power. Sensitive disposition, timid 
and insincere character. 

Actual daily dose: 1.2 (i8 T ^ grs.) morphia sub- 
cutaneously. 

Entered for treatment Aug. 1, 1884. Condition: 
Weight 155 lbs.- Marked tremor of hands; difficulty 
of speech; twitching of facial muscles in speaking: 
pale face; hollow eyes; copious sweating; coated 
tongue; pressure upon the stomach painful. 



— 94 — 

Heart beat heard over larger area. Pulse about 
ioo. Patellar tendon reflex all right. Urine free 
from albumen. 

Aug. i. Had taken himself 0.36 (5 J grs.), given 
by me 0.5 (7^ grs.), altogether 0.86 (13 grs.). 

Aug. 2. Slept without interruption. No special 
disturbance. Whole amount 0.36 (5J grs.). 

Aug. 3. Slept little. Yawning. Pain in the 
back. Ate well. Smoked. Whole amount 0.28 

(4 g rs 0- 

Aug. 4. Slept but little. Much diarrhoea. Ate 

well. Smoked several cigars. Whole amount 0.16 

(4 grs.). 

Aug. 5. Toward 3 a. m. uneasy, then fell asleep 
after an injection of 0.05 (| gr.) and slept until 9 
a. m. Felt well. Took nourishment enough. Thought 
he had not felt so strong for a year as to-day. Pulse 
regular, strong. Vomited during the evening, before 
the injection. Whole amount .10 (1^ grs.). 

Aug 6. Slept until about 3 a. m., then uneasy; 
got up and walked round the room; lay down again in 
bed. In the morning about 8 a. m. felt very badly, 
pale; slept later, from 10 to 11 a. m. and from 12 to 
1:30 p. m. No appetite; tongue not coated. Pulse 
regular, 100. Whole amount 0.06 (^ gr.). 

Aug. 7. In the beginning of the night uneasy, 
excited. Drank much cognac. Later more than one 
hour sleep. Pulse 8 a. m., 72-86, regular full. No 
vomiting, once diarrhoea. Tongue clear. During the 



— 95 — 
day pretty active. Pulse, evening, 88. Whole amount 

0.03 (-A g r -)- 

Aug. 8. Much pain in the hips during the night 
Slept very little. From 5 to 6 a. m., very excited and 
uneasy, then fell asleep toward 12 m. No vomiting, 
afternoon diarrhoea, uneasy and anxious; 20 drops of 
laudanum, then fell asleep. In sleep 2 pollutions, 
Whole amount 0.005 (tV £ r -)- 

Aug. 9. Slept little; wandered much about the 
room. In the morning complained of feeling anxious. 
Pulse 104, regular. Once diarrhoea; increased sneez- 
ing; no vomiting; appetite less; 20 drops of laudanum. 
Afternoon again anxious; pulse 92; diarrhoea 3 times. 
During sleep which occured in the day of one-half 
to three-quarters of an hours duration, pollutions oc- 
curred. Evening 20 drops laudanum. 

Aug. 10. Slept well from 10 to 2 a. m., then 
awoke but remained quiet in bed. Morning again 
anxious; pulse 92; once diarrhoea; sneezing and 
yawning; appetite better. Afternoon severe pain in 
the bowels with repeated diarrhoeal discharges, 0.5 
(7i & r -) bismuth, with 0.15 (2^-gr.) opium; bad humor; 
pulse 92. 

Aug. 11. Slept well several hours; had no diar- 
rhoea; morning in the garden; pulse 108; tongue 
coated; vomiting and sneezing gone. Anxious to- 
ward evening, diarrhoea again; bismuth 0.5 (7^ gr.), 
with 0.15 (2J gr.) opium. 

Aug. 12. An attack of asthma in the night, 0.01 



- 9 6- 

(^ gr.) morphia per mouth; feels well; uneasy; gave 
several full doses of bromide; ate little; toward even- 
ing, again, difficulty in breathing; o.oi (i gr.) morphia 
internally. 

Aug. 13. Slept several hours; after which felt 
strong and much better; some diarrhoea; sol. pot. 
bromide as yesterday. In the afternoon was very cheer- 
ful and even lively. Evening 0.01 Q-gr.) morphia in- 
ternally. 

Aug. 14, Slept but little, in spite of that he feels 
well to-day. Pulse 104; appetite has increased; de- 
sires nourishment; goes to walk; weight 147 lbs. 

Aug. 19. On the whole in fair condition; sleep was 
still something to be desired. 

Aug. 22. Slept very well; breaths visibly; always 
many pollutions. 

Aug. 26. Weight 152 lbs. 

Sept. 9. Weight 157 lbs. 

Sept. 14. Left the hospital to-day in good physi- 
cal health; weight 160 lbs.; sleep sometimes not over 
5 hours duration. Has become engaged to his nurse. 

Writes on the 8th of October that he is getting 
along excellently; " sleeps like a log." 

Married in November. 

In January, gastric catarrh, with much debility, 
and insomnia. The patient was unable to attend to 
his business; felt terribly prostrated; vague pains, 
whining disposition, etc. I ordered, three times daily, 
0.1 (iJ4 gr.) opium, strong wine, powerful nutrients. 



— 97 — 

In 10 to 14 days his condition was again normal. 

A second and similar attack developed in [April. 
Patient came here in the company of his wife (April 
18). Condition : 169 pounds; anxious, excitable; 
rapidly advancing exhaustion; desire for sleep; appe- 
tite and digestion good; trembling of hands and facial 
muscles; patellar tendon reflex increased; some pain- 
ful vertigo; heart in order. 

Treatment : Galvanism; warm baths; bromine 
water; forbidden to drink coffee and to smoke. 

Was here until July 10th, and has recovered. 
Marked increase in weight, 15 pounds (184). 

Convalescence continued in the Black Forest. I 
have corresponded with the patient, and can affirm that 
he has not had a relapse since the first withdrawal at my 
institute. His wife, his former nurse, who has mean- 
while borne him a son, confirms this statement. 

CASE VII. 

Morphia habit of four years 1 duration; fatty heart. 
Second withdrawal in 7 days. Weak on accotmt of 
weakness of heart. Convalescence of 2j days. After 
treatment in Schwalback. 

Mrs. Dr. B., wife of a physician; 32 years old. 

Cause: Pain in back from vertebral disease; be- 
gan using morphine 4 years ago. 

First withdrawal, 1881, by the gradual method. 
Remained free until 1883. Began again on account 
of trouble with the stomach. While taking the morph- 

8 FF 



— 98 — 

ine her menses stopped. Actual daily dose 0.6-0.8 
(to £ r - t0 J 4 g r -) morphia subcut. 

She is very lean; large abdomen, fatty heart, weak 
heart-beat; weight 86 pounds. 

Entered June 12, 1882. To-day she herself took 
0.2 -f- 0.25 (3 gr. -f- 3f grs.): was given by me, at 11 
p. m., 0.15 (2 J grs.). Total, 0.6 (9 grs.). 

June 13. Slept much during the night, but 
uneasily. 8 a. m., pulse 100, small; 0.075 ( X ^V & rs -)- 
3:15 p. m., 0.08 (1^ grs.); previously there was marked 
sweating, shivering, yawning, irregular pulse. Ate 
well. 5 P.M., bath. 11:15 p. m., 0.08 (ij grs.). Total, 

o-235 (3it grs.). 

June 14. Slept well from 12 to 6:30 a. m.; then 
strong craving, shivering, yawning; dragging pain in 
legs. 8 a. m., 0.06 (y 9 ^- gr.). Breakfast as usual. 
Slept from 12 m. to 3:15 p. m.; then pain in the 
bowels, yawning. 3:30 p. m., 0.06 ( 1 gr.). Bath. 
Felt better. Much lachrymation. Drank a bottle of 
beer. Supped as usual. 11:30 p. m. 3 0.06 (^ gr.). 
Total, 0.18 (2 T *j- grs.). 

June 15. Slept from 1 to 6:30 a. m., then nausea, 
some vomiting and profuse sweating; 8 a. m., 0.04 
(| gr.); about noon two hours' sleep; 3:30 a. m., 0.04 
(f gr.); profuse sweating; bath; then all symptoms 
of abstinence disappeared; ate very well; 11:15 p. m., 
0.04 (f gr.); total 0.12 (if grs.). 

June 16. Slept from 1 to 3 a. m., 4 to 5 :3o a. m.,1 
6 a. m., very bad; vomited; 8 a.m., 0.03 ( T 6 ^gr.); 



— 99 — 
shivering; disinclination to eat; drank only water; 
refused alcohol; 3:15 p. m., 0.03 (^ gr.); pulse very 
weak, irregular, 96; 7:15 p. m. bath, after which weak; 
8 p. m., 0.03 ( T 6 3- gr.), then pulse was strong and regu- 
lar, 92; drank bouillon and port-wine; 11 p.m., vomit- 
ing, attended with pain in stomach; 11:45 p - M -> °«° 2 
{Yz gr.); total, 0.11 (if grs.). 

June 17. Slept from 12:30 to 2 p. m., then pain 
in the stomach; later, vomited; 3 a. m., 0.02 (}i gr.); 
chill; cold feet; port-wine; from 5 to 8 a. m., slept, 
followed by some strangling; pulse 76, strong and 
regular; 8 a. m., twenty drops of laudanum; bouillon 
alternated with cognac, hourly; 12 m., twenty drops of 
laudanum; 1 p.m., o.oi (^5 gr.) morphia subcutane- 
ously; bouillon with egg; felt better; 5 p. m., fifteen 
drops of laudanum; 7 p. m., strong desire for laudanum; 
10 p. m., uneasy; pulse 96, powerful; total, 0.03 ( T 6 3 gr.). 

June 18. 1 a. m., o.oi (^5 gr.) morphia subcu- 
taneously; said it had no more quieting effect than 
water; 2 a. m., twenty drops of laudanum, when she 
fell asleep, which continued until 6:30 a. m.; drank 
wine; 8 a. m., asked for a bath; cheerful; read the 
newspaper; 11 a. m., half hour in the garden; later, 
severe vomiting; diarrhoea; laudanum was rejected; 
subnitrate of bismuth 0.5 (7^ grs.) opium pur, 0.05 
(H & r given by mouth; gruel. 

Afternoon, quiet; evening, cheerful; pulse 73, 
strong; total, 0.01 (}£ gr.). 

June 19. Did not sleep; condition moderate; 



Carlsbad salt on account of badly coated tongue; two- 
doses of bismuth, 0.2 (3 gr.), and opium, 0.05 (1 grain;) 
weight, 130 lbs. (loss of 9 lbs.); ate and drank well; 
vomited once; slept several hours; bath; walked in the 
garden. 

June 20. Did not sleep; vomited; (suffered from 
habitual vomiting before the morphia habit was taken 
up); powders of bismuth and opium; has recovered by 
degrees, only sleep has always been poor; pulse weak; 
heart-beat irregular; patient becomes tired easily. 

July 18. Sent to Schwalbach for after-treatment 
(Dr. Bohm), where she made a good recovery after 
suffering considerably at first. According to report 
of my colleague, Dr. Bohm, she was there again in the 
summer of 1885, in very good condition; there had 
been no relapse. 



APPENDIX I. 

ZAMBACO ON THE TREATMENT OF MORPHIO- 
MANIA.* 

This writer condemns the sudden suppression as 
dangerous. Certain authorities, it is true, have pre- 
ferred the immediate and complete manner of with- 
drawal, but besides the fact that this method is very 
difficult to carry out, it renders the patient liable to 
grave symptoms of collapse, which must be avoided. 
A similar result follows the attempt in inveterate cases 
of alcoholism to suddenly suppress the use of ardent 
spirits; we know that delirium tremens is a conse- 
quence of this abrupt discontinuance. The rule is 
not, however, general, for in the case of the tobacco 
habit, it is better at once to leave off altogether, 
break all the pipes, and throw away all the tobacco, 
rather than allow the theoretical diminution of one 
cigarette a day. 

It is better, then, progressively to diminish the 
daily dose of morphine, act slowly, and sometimes 
make the decrease not more than several fractions of 
a gram a day, even at the risk of making the treatment 
last several months. 

Two modes present themselves here, between 



* Semaine Medtcale, vol. 5, p. 75 (summarized by Prof. 
Grasset, from L'Encephale). 



102 



which we may hesitate: Shall we diminish the number 
of daily injections, or is it better to diminish the quan- 
tity of morphine injected each time? 

" If, as ordinarily happens, the morphinist is very 
regular in the time of his injections, making his four, 
six or more injections at the same hour every day, it 
is a good plan to continue this course and reduce the 
dose of morphine in each injection. In an inveterate 
morphinist whom I recently successfully treated with 
my colleague Carrieu, we permitted the four daily in- 
jections almost to the end of the treatment, only each 
injection contained a little less morphine than the cor- 
responding injection of the day before. 

" It is necessary also to compare each injection 
with that of the day before made at the same hour, for 
it ordinarily happens that this injection — that of the 
evening or that of the morning — is larger than the 
others; and this proportion ought to be kept up 
during the whole time of the treatment. 

"Another question presents itself: Should these 
diminutions in the quantity of morphine be made 
without the knowledge of the patient, or with his con- 
sent? 

" This depends, evidently, on circumstances, and 
it is impossible to lay down any general rule. I 
believe, however, that in most cases it is best to give 
them both with and without the knowledge of the 
patient. 

" First of all, I establish the principle that w T e can- 



— io3 — 

not cure a morphinist in spite of himself. It is neces- 
sary that he should give his consent, and that he 
should do this heartily. Moreover, it is desirable that 
the patient should co-operate in the treatment, and for 
this reason he should be aware of the progressive 
diminution of the doses. 

" One may, however, often without the knowledge 
of the patient reduce the dose more than he has any 
idea of. Thus, if the patient consents to diminish the 
injection by one or two drops, you can at the same 
time make the solution more dilute; this should be 
done so regularly and progressively that there would 
be no abrupt change. 

" In this event, the patient will never be aware of 
the fraud, or will not be aware of it till the end of the 
treatment, when there will be no occasion for any re- 
sistance. 

" In order that all these rules may be carried out, 
it is indispensable that the physician shall have abso- 
lute and complete control of the treatment. He must 
keep in his possession the solution of morphine, and 
must personally make the injections, but if for any 
reason this is impossible, he must himself give the pa- 
tient every day the supply of morphine which is to 
last him during the next twenty-four hours. 

" In order that the attending physician may not 
be thwarted in this regulation, he must see that a secret 
but thorough watch is exercised over the patient, in 
order that the latter may not be able to procure mor- 



— 104 — 

phine of the pharmacists; he must satisfy himself that 
the latter has not in his possession any prescription, 
old or recent, whereby he might obtain the drug. 

" As the majority of morphinists are hysterical or 
become so, are mentally unsound or are becoming so, 
it is necessary that even greater precautions should be 
taken. Some will go so far as to forge prescriptions 
with the signature of physicians generally unknown to 
the apothecaries, so that the latter are unable to ascer- 
tain whether the prescriptions are genuine or not. 

" In order to avoid being baffled in this way, it is 
well for the attending physician or the family, in a 
small city, for instance, to warn the apothecaries to be 
on their guard against a fraud of this kind; and to aid 
them in this, an accurate description -of the patient 
should be given them; and I repeat, the patient should 
be watched with the utmost assiduity. 

"These are the precautions to take in order to 
render real and efficacious the diminution of morph- 
ine in each injection. 

" Often, also, and notably when the injections are 
too frequent during the day, the number of the injec- 
tions may be profitably diminished; and when you are 
prepared to leave them off altogether, the last to sup- 
press is that of the early morning, the one which 
comes before the principal meal, and the night injec- 
tion. 

" This advice is good as a general rule, but there 
are exceptions. In order to determine the injections 



— io5 ~ 

which are most necessary, you must first know ex- 
actly the cause of the morphine habit. This is one 
side of the question whose importance is not suffici- 
ently emphasized. All morphiomaniacs are, doubtless, 
more or less like each other as far as the symptoms of 
the disease are concerned. The end to attain in all 
of them is the same, but all have not contracted their 
deplorable habit from the same motive. 

" One has rheumatic pains, another gastralgia, 
another insomnia. The treatment in its entirety must 
take great account of this etiological element. Too 
often the physician has in view only the poison and 
its consequences on the patient, and does not go back 
to the causes of the baneful habit. Consequently he 
does not endeavor at the same time to #strike at the 
original cause as well as the results in the baneful 
morphine habit, and hence does not cure the morph- 
inism, or if he does cure it, it is for a very short time, 
and a relapse is sure to follow. 

" Every morphiomaniac ought, then, to undergo, 
at the onset, a thorough examination as to his present 
state and as to his entire previous history; and along- 
side of the diagnosis of morphinism, should be laid 
down the diagnosis of the disease which has led to the 
abuse of the poison, for one never becomes a morph- 
inist except as the result of a disease. Slight or grave, 
functional or organic, disease of some kind always 
exists in the morphiomaniac. If a human being 
should make injections of morphine without motive, 



— ic6 — 

without pain to assuage, without symptoms to remove, 
this would be a sign of real mental aberration; now 
this is of itself a disease. 

k - A knowledge of this previous disease is of a cap- 
ital importance for the institution of the treatment, 
and is fundamental also for the prognosis. 

"What makes the diagnosis especially difficult, in 
certain cases, is that we must carefully distinguish in 
the patient what in the observed symptoms belongs to 
the morphinism itself, and what depends on the pre- 
vious disease. Thus, in certain hysterical morphio- 
maniacs, this distinction is often difficult to make. 
The bases of this differential diagnosis are to be found 
in connection with the study of the symptoms of the 
morphine habit; I cannot here dwell upon this subject 
as it relates but indirectly to the matter of treatment, 
with which we are now concerned. I will content 
myself with laying down this general principle, that it 
is indispensable for the successful treatment of mor- 
phiomania to fathom the cause of the habit. We see, 
at once, the application of this principle to the par- 
ticular point which we are studying, i.e.. the determi- 
nation of the injections which should be respected the 
longest in the morphinist; thus it is evident that in the 
gastralgic patient the most important injection and 
the last to suppress is that which comes before the 
meal; in the patient affected with insomnia, it is the 
injection of the evening which should be the last 
omitted. 



— 107 — 

II. 

So much respecting the manner of diminishing 
the morphine; by what medicines must we replace 
the baneful drug, in order to mitigate the transition, 
and facilitate a cure ? 

Zambaco recommends especially alcoholic stimu- 
lants. In patients, more particularly, who resort to 
morphine for a stimulus to intellectual activity, there 
is no doubt as to the utility of generous wines, cog- 
nac, 'champagne, old whisky, and these alcoholic pre- 
parations should be given, he says, at the risk of 
producing drunkenness; we may thus substitute for 
the first kind of intoxication a second, which can be 
more easily cured, because not being inveterate. At 
all events, the usage of wine and brandy in moderate 
doses contributes to the cure of morphinism in concert 
with the tonics and sedatives of the nervous system. 

There are notably, during the treatment of mor- 
phinism, phases of depression and prostration, periods 
when the patient cannot rise from his arm chair or his 
bed all day long; when he feels as if there were no 
life in his arms and legs, and when the moral gloom 
or discouragement intensifies and complicates the 
physical oppression. It is then that alcohol and all 
the stimulants of the nervous system are useful. 

In the same group, and to fulfil the same indica- 
tion, we would place caffein, coffee, carbonate of 
ammonia; even injections of ether, which have a tem- 
porary but good effect if the patient is threatened with 
true collapse. 



— io8 — 

III. 

As sedatives, we may employ the bromides and 
opiates. The indications for these two orders of means 
are different. 

The bromides are applicable particularly to a gen- 
eral neuropathic condition, to enervation, to a state of 
hyperexcitability, to hystericism. The preparations of 
opium are more particularly indicated in painful con- 
ditions, and sometimes where there is an insomnia 
that nothing will so well relieve. It need hardly be 
said that the gummy extract of opium is meant, or 
laudanum, taken by the mouth. 

For the insomnia itself, chloral and other medi- 
cines of this group are in general superior to the 
opiates. Moreover, chloral may be efficiently com- 
bined with opium or the bromides when there is an 
indication for one or the other of these remedies. 

Paraldehyde, condemned by Erlenmeyer, is spoken 
favorably of in the treatment of morphinism by Dujar- 
din-Beaumetz, Constantin Paul and Zambaco. The 
latter has obtained good effects from this remedy in 
cases that were rebellious to all other drugs. Two or 
three grammes (thirty to forty-five grains) are added 
to a glass of grog, and a tablespoonful is given every 
ten minutes till sleep is produced. Zambaco believes, 
despite the severe condemnatory sentence of Erlen- 
meyer, that cocaine may render excellent service in 
some cases, especially when there is an indication to 
combat pain of a mucous membrane. In gastralgia, 



— 109 — 

cocaine, by its double property of analgesic of the 
gastric mucosa and excito-motor of the muscular coat, 
has often a charming effect; it acts the part of both 
morphine and strychnine to the stomach. 

But what cocaine does for the stomach, it also 
does for the other mucous membranes, and especially 
for those which are accessible, such as the vulvar and 
vaginal mucosae, the mucous membranes of the 
bladder and urethra, etc. In fact, what opium taken 
internally does for pain, what chloral, paraldehyde 
and urethan do for insomnia, what the bromides do 
for hyper-excitability or neuropathy, cocaine specific- 
ally does for the pains of the mucous membranes. 
We ought then to choose among these medicaments 
the agent which is best adapted to the nature of the 
case, and especially to the original cause of the mor- 
phine habit. Water under all its modes is a very 
powerful adjuvant in the treatment of morphiomania. 
Affusions, douches and lotions with cold water are not 
only stimulants but tonics to the nervous system. 
They not only combat the phenomena of actual de- 
pression, the threatenings of collapse of the moment, 
but they seem to arouse the entire nervous system, 
and often suppress the cause itself of the malady. 
This is what happens notably with hysterical patients 
for whose disease hydrotherapy is almost the only 
treatment. 

If, on the contrary, the leading indication is to 
calm the patient and produce sleep, prolonged warm 
baths are useful. 



Zambaco rightly recommends these baths. The 
warm bath is an excellent remedy for general nervous- 
ness and nervous insomnia. It is in such cases that 
one might be tempted to try those long sojourns in 
the water which Hebra recommends in certain cutane- 
ous diseases and which Baelz advises in certain states 
of neuropathy. 

By the side of hydrotherapy, we must place elec- 
trotherapy and hypnotism. 

Common people have formed concerning electri- 
city the notion of an agent eminently stimulant, which 
causes the muscles to contract, the limbs to jerk, and 
the face to assume various grimaces. Physicians 
know how, according to circumstances, to make this 
agent a means of sedation as well as of stimulation. 

We recommend, especially, for this end, the pro- 
longed Franklinic bath; a sojourn of forty or fifty 
minutes on the insulated stool calms the nervous sys- 
tem, while it has a general tonic effect, arouses nutri- 
tion, and often procures sleep. 

As for hypnotism, it may act in two ways; first, 
the induced sleep, even when it is brief, greatly calms 
the nerves. Then, when the operator has completely 
succeeded, he has in his suggestions a powerful means 
of influencing the patient. He will enjoin upon him 
not to think longer of his sufferings, telling him that 
they no longer exist; to make no longer hypodermic 
injections, as there is no longer need thereof, etc.; this 
proves a powerful adjuvant to the authority of the 



— Ill — 

physician. Hypnotism here becomes a means of great 
benefit, as in all the neuroses. Lastly, the moral 
treatment must not be overlooked in the therapeutics 
of morphinism. It is necessary, at the very onset, to 
point out to the subject the dangers to which he is 
exposed by his deplorable habits; to show him plainly 
the cachexia, and physical dilapidation, the mental 
alienation and death, which are the possible as well as 
the probable results of addiction to morphine. The 
patient must be convinced, and his implicit obedience 
must be obtained; recovery is at this price. As I 
have said above, we can cure only those morpho- 
maniacs who wish to be cured. 

IV. 

These considerations lead logically to the ques- 
tion of the place where the morphiomaniac should be 
treated. 

We cannot by force sequestrate any but madmen. 
Zambaco says, indeed, that sequestration becomes pos- 
sible when the resistance of the subject is equivalent 
to suicide. 

I am not of this opinion, and I do not believe 
that we can sequestrate an individual who wishes to 
commit suicide unless he be insane. 

But apart from this forced sequestration, of which 
I do not speak here, there is the question as to whether 
we ought to treat the morphiomaniac in his own family 



or apart from his family: the reply depends on certain 
conditions. 

Removal from the family is an excellent means of 
treatment in most nervous diseases; it is often the ab- 
solute condition of success in hysteria. If, then, in 
the family of the morphinist you cannot realize the 
conditions of a hospital, if the parents continue to yield 
to the demands or entreaties of the patient, if the 
physician cannot be absolute master of the hygiene as 
well as of the food of his patient, of his walks and his 
pleasures, as well as of his medicines and injections, 
there is no reason for hesitation; the patient should 
be removed from his pernicious environment and 
placed in some institute for nervous patients (I do not 
mean, of course, in a lunatic asylum). If, on the 
other hand (what is sometimes realized), the family is 
powerful enough, intelligent enough, and confident 
enough, to make their home as good as a sanitary in- 
stitute, if the physician is aided by and has the obedi- 
ence of all the family, and if his directions may be 
carried out to the letter, it is better to Jeave the patient 
with his family, who can in many cases procure him 
diversions and occupations impossible to be obtained 
in a hospital or medical institute however well organ- 
ized. 

Such, in brief, are the teachings of one of the 
best living authorities respecting the new social evil 
and the remedy. 

Something remains to be said about the preven- 



— H3 — 
tive treatment. How are we to stay the spread of this 
baneful habit? 

"I do not advise physicians no longer to make 
morphine injections, nor even to lessen the number of 
prescriptions of morphine. This would be to deprive 
ourselves of our best remedial agent in certain cases. 

" But I believe that there would be far less mor- 
phiomaniacs, if, on the one hand, physicians would 
always insist on themselves making hypodermic injec- 
tions of morphine for their patients, never entrusting 
their syringe and morphine to anybody, and if on the 
other hand, pharmacists would never fill a prescription 
for morphine except the exact number of times in- 
dicated on the blank, and ■ once only when there is 
nothing stated to the contrary. I am convinced that 
this very simple rule would virtually put an end to 
morphinism, without depriving therapeutics of a 
precious remedy which is discredited indeed, though 
unjustly, by reason of the abuse that has been made 
oi it. 

9 FF 



ELIXIR NATIVE COCA. 



(JLORINI.) 



An Elixir of* Bolivian Coca-Leaves (Eryll&roxylon Coca) 

Prepared Exclusively for Parlte, Davis A; Co. in tine locality 

where they are Grown, from Leaves Freshly Gathered. 



Eaeh fluidounce represents GO grains fresh native cocm-leaves* 

" This elixir of Coca-leaves, prepared in the native habitat of the drug, differs 
from all other preparations of coca in containing all the original constituents of the 
native leaves. It has now become well-known that coca-leaves suffer very extensive 
changes in transportation, and that there are no means by which these changes can 
fee prevented. That the loss begins as soon as the leaves have been collected is 
shown by the fact that the Indians themselves refuse to accept the leaves after they 
have been dried for a few weeks." — Coca at Home, by. Dr. Rusby, Therapeutic 
Gazette, March, 1888, p. 165. 

Experience has shown that from cocaine, the only appreciable constituent of 
exported leaves, the characteristic effects of coca-chewing cannot be obtained, in 
any degree. Obviously, these effects are to be obtained only by the use of a prepar- 
ation of the recent leaves. This elixir, made for us from carefully-selected leaves 
immediately after they are collected, represents their full strength, and possesses 
the stimulating and supporting powers of the native drug. Representing only two 
ounces of dried leaves to the pound, each fluidounce contains only about a quarter 
grain of cocaine, so that its continued use is free from the objectionable features of 
that drug. 

Of the therapeutic effects of coca-leaves in their original condition our knowl- 
edge is limited, as their use has been heretofore necessarily restricted to the country 
where grown. But trials that have been made with this preparation by leading 
practitioners, and its extensive use in Bolivia, fully warrant us in recommending it 
in the following conditions : 

1. In exhaustion due to excessive physical or mental strain, or resulting frooa 
disease. 

2. In pneumonia and kindred diseases involving difficult respiration. 

3. In dyspepsia, either gastric or intestinal, of the atonic type. 

The dose is a fluidounce. and should be taken immediately after eating. 
It is earnestly requested that physicians should make known the results of thwc 
trials of this preparation. 



PARKE, DAVIS & CO., 

Detroit - and - New York, 



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'By A/B. Palmer, M. D. 

Intestinal Diseases of Children. 
By A. Jacobi, M. D. 



The Modern Treatment of Headaches. 
By Allan McLane Hamilton, M. D. 

The Modern Treatment of Pleurisy and 
Pneumonia. 

By G. M. Garland, M. D. 

How to Use the Laryngoscope. 
By J. Solis Coh'rifM. D. 

Diseases of the Male Urethra. 

By Kessenden N. Otis, M. D. 
The Disorders of Menstruation. 

By Edward W. Jenks, M. D. 
The Infectious Diseases. In 2 vol* 

By Karl Liebermeister. 



SERIES III. 



Abdominal Surgery 

By Hal C. Wyman, M. D. 

Diseases of the Liver. 

By Dujardin-Beaumetz, M.D. 

Hysteria and Epilepsy. 

By J. Leonard Corning, M. D. 

Diseases of the Kidney. 

By Dujardin-Beaumetz, M. D. 

The Theory and Practice of the Ophthal- 
moscope. 

By J. Herbert Claiborne, Jr., M. D. 
Modern Treatment of Bright's Disease. 

By Alfred L. Loomis, M. D. 

Clinical Lectures on Certain Diseases of 
Nervous System. 

By Prof. J. M. Charcot, M. D. 



The Radical Cure of Hernia, 

By Henry O. Marcy, A. M., M. D.* 
L. L. D. 

The Treatment of Diseases of.the Blad- 
der, Prostate and Urethra. 
By H. O. Walker, M. D. 

Dyspepsia. 

By Frank Woodbury, M.D. 

The Treatment of the Morphia Habit. 
By isrlenmeyer. 

The Etiologly, Diagnosis and^Therapy of 
Tuberculosis. 

Ry I'rof. H. von Zi ems sen. 



SERIES IV. 



Nervous Syphilis. 

By H. C. Wood, M. D. 

Education and Culture as correlated to 
the Health and Diseases of Women. 
By J. V. C. Skene, .vi. U. 

Diabetes. 

By a. H Smith, M. D. 

Rheumatism and Gout. 

By F. Leroy satterlee, M. D. 

Hypodermic Medication. 

By Bourne, i;ie and Bricon. 

A Treatise on Fractures. 

By Armand i^espris, M. D. 



Neuralgia. 

By £. P. Hurd, M. D. 

Auscultation and Percussion. 

By Frederick C. bhittuck, M. D. 

Practical Points in the Management of 
Diseases of Children. 
By I.N. Love, M. D. 

Electricity its application in Medicine. 
By Wellington Adams, M. D._ j 

Taking Cold, 

By F. H. Bos worth, M. D. 

Some Minor and Major Fallacies con- 
cerning Syphilis. 

By E- L. Keyes, M. D. 



GEORGE S. DAVIS, Publisher, 

F. O. Box: 470. Detroit, Oriels. . 






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